SOAP NOTES

Overview

Progress notes provide an “organized method of planning, giving, evaluating, and recording rendered client services. A viable method of record keeping is SOAP noting.  SOAP is an acronym for subjective (S), objective (O), assessment (A), Plan (P), with each letter representing one of the sections of the case notes, (Cameron, et al, 2002, p. 286).”  Most agencies also have a deadline regarding when documents must be completed and entered into the client’s file.  Progress notes are usually required within 24-48 hours after as session.  Widely utilized in medical settings, it is also common within the counseling field.

Problem Solving Process

A textbook of mine describes the process of clinical case formulation defining it as: “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (Ingram, 2012, p. 3).”  Essentially, this process involves four basic steps: (1) identifying the problem, (2) seeing explanations for them, (3) plan implementations, (4), defining goals, (Ingram, 2012).

  1. GATHERING DATA:  includes subjective and objective data, it is free of assumption, interpretation and/or diagnosis (Ingram, 2012).
  2. DEFINING THE PROBLEM:  stated in simple terms, the problem should be defined as solvable targets for treatment.  It should be comprehensive and complete, reflecting client’s values & not the counselors (Ingram, 2012).
  3. GOALS & OUTCOMES:  There should be a logical relationship between the problems and goals.  They should be realistic, attainable, and testable. Ingram, (2012) describes core clinical hypotheses as useful in these cases and defines them as follows: “a single explanatory idea that helps to structure data about a given client in a way that leads to be better understanding, decision making, and treatment choice, (p. 11).”  
  4. TREATMENT PLAN: includes a description of interventions used to address the client’s problems.  Includes process goals and outcome goals.

Components of the SOAP NOTE

Subjective vs. Objective

Ingram (2012), provides a clear differentiation between subjective and objective data in the folloiwng statement: “What the client ells you goes in [SUBJECTIVE DATA}…how the client tells it goes in [OBJECTIVE DATA], (p. 83).” In other words, the subjective section provides the client’s story in their own words.  The objective data contains observations on how the client tells the story.

(S) Subjective

The purpose of subjective data is to provide a place where the client’ own story can be told.  For this reason, it contains information from the client and the client’s family.  “Without losing accuracy, the entry should be as brief and concise as possible; the client’s perceptions of the problem(s) should be immediately clear to an outside reader, (Cameron, 2002, p. 287).”  Quotations should be kept to a minimum, however important statements pertaining to thoughts such as SI and/or HI, for example should be included.

What client tells you.
What significant others tell you.

(O) Objective

The objective data includes clinical observations, medical records, and the therapist’s impressions.  It excludes case formulation and information pertaining to either the client or family members’ verbal reports.  Objective information should be factual, “written in quantifiable terms – that which can be seen heard smelled, counted, or measured.”  Objective information included can come either from outsider records or the counselor’s observations.  Include information which is precise and descriptive, (i.e. “As evidenced by”).  Words with negative judgments that are open to interpretation should be excluded.   During my practicum class, the instructor required us to include the following: (1) general, (2) speech, (30 psychomotor, (4) mood, (5) affect, (6) thought, (7) insight & judgment, (8) impulse control.

factual information
counselor observations
Information from outside records

(A) Assessment

This section provides an overview of the client’s clinical judgment.  It draws on information from the subjective and objective sections.  It often lists client’s symptoms, diagnoses, and clinical impression.  Cameron, et al, (2002) notes: “the assessment portion of the SOAP notes is the most likely section to be read by others, such as outside reviewers auditing records, (p. 289).”

Summary of counselor’s clinical judgment.
Synthesis of information from subjective & objective sections.

(P) Plan.

Consisting of the plan and prognosis, information here can include a list of future interventions, appointments, treatment progress, and/or psychoeducation.  “the prognosis is a forecast of the probable gains to be made by the client given the diagnosis, the client’s personal resources, and motivation to change, (Cameron, et al, 2002, p. 289).”

Plans for therapy
Overview of treatment plan
Description of client’s prognosis.

An Example of a SOAP NOTE…

This example comes from my practicum class in which I recorded a series of sessions with an individual who was “playing the part” of a character.  Therefore, it does not pertain to an actual client, and is a byproduct of a hypothetical exercise.    Additionally, since it is important to keep in mind, this was my “first” effort at every doing a progress note, (therefore its far from perfect)… 🙂

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POMR – An Alternative to SOAP

Cameron, et al, (2002) also discuss an alternative to the SOAP Format. POMR is an acronym which stands for “Problem-Oriented Medical Record.  It begins with a review of the clinical assessment and continues with a list of problems derived from this history.  It concludes with a treatment plan and progress note.  To read more about this document click here.  It is utilized commonly within the health care field it contains four components:

  1. Data Base – History

  2. Physical Exam and Laboratory Data

  3. Complete Problem List

  4. Initial Plans

  5. Daily Progress Note

  6. Final Progress Note or Discharge Summary

Resources & References

Template of Information to Include in SOAP Note…

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development: JCD, 80(3), 286-291
Ingram, B.L. (2012). Clinical Case Foundations: Matching the Integrate Treatment Plan to the Client. (2nd. Ed.). Hoboken, NJ: Wiley.

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Biopsychosocial Assessment

BASIC SID….

Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43).   Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).

Click here for my post on the BASIC SID..

Resources

 EXAMPLE OF A BIOPSYCHOSOCIAL ASSESSMENT

HERE IS AN ONLINE BLANK FORM

Key Components of a Biopsychosocial Assessment

At my internship, the biopsychosocial assessment occurred during my first meeting with the client over a two hour period.  This document includes the following key components, ensuring all relevant information is addressed adequately.

Demographic Data

This includes the obvious identifying information for the client including name, DOB, identification number, address, & method of payment.  Other information can include: race, sex, marriage status, and employment.

Presenting Problem

What is the client’s stated reason for entering therapy? Obtaining information on the presenting problem includes not only the nature and history of their current complaints, but their goals for therapy.  In other words, what does successful resolution of this issue look like?  Sometimes intake forms include a current symptom checklist .  This can be a point of discussion, to further define the presenting problem.
  1. The Therapist’s interpretation of the problem:

    1. What is the history, nature, extent, and severity of the problem?
    2. What are the client’s personal treatment goals as it pertains to this problem?
    3. What barriers exist to the achievement of these goals?
    4. What are your observations and feelings overall about the presenting problem.
  2. The Client’s Interpretation of the problem:

    1. What does the client say the reason for coming to therapy?  
    2. ASK:  Why were you referred? or What are some things you might need to work on or would like to see get better?
  3. Family’s Interpretation of the problem. 

    1. What does the family say about the client?  If no family is present than just say no collateral obtained.
    2. ASK:  What does SUZY need to work on or what things can improve?
  4. Others to ask:  referral source, caseworker, school, etc…

PSYCHOLOGICAL: Mental Health History…

Biopsychosocial exams also include a psychiatric history section.   What is the client’s past history with psychiatric treatment, (i.e. outpatient, inpatient, medication list)?  Has the client been diagnosed with a mental illness previously?  My internship site also includes a substance abuse history, spiritual assessment here.  Sometimes these forms include a mental status exam section and functional assessment.
  1. Psychiatric History (hx treatments, diagnoses, medications, etc).

    1. Current Mental Health Symptoms:  What symptoms are they currently displaying?  How long have they been occurring?  symptoms should correlate to the diagnostic criteria
    2. Past Diagnoses: (List any diagnosis from previous providers.  If unknown, write “unknown”)
    3. Previous Mental Health Treatment: Any past providers? Who and how long?  What worked and did not work?  Any medications in the past?
  2. Mental Status Exam & Functional Assessment.

    1. Click Here to Read About the MSE
    2. Current level of mental and physical functioning (describe impairments and skills within to justify)
      1. Mental:  Your interpretation of the client and how you feel their symptoms are affecting their life.  I also include justification for diagnosis..  
      2. Physical:  How is their physical health impacting their functioning?  Do they need to follow up with a PCP?
      3. Co-Occurring disabilities, disorders and medical conditions:  Are there two diagnosis occurring at the same time?  Are you ruling out diagnosis?  IS there substance use or medical issues along with mental health?
    3. Click Here to Read About WHODAS-2
  3. Substance Abuse History (sometimes a separate section).

    1. When discussing the client’s substance use history ask the following:
      1. (typical amount/typical frequency/duration/age at first use/Date last use)
      2. (Tobacco/alcohol/marijuana/opioids/Amphetamines/Cocaine/Hallucinogen/Caffeine.
    2. Client Treatment History: the client had any substance use treatment?
    3. Any known family history of use or any know treatment for such?  
  4. Assessment of risk-taking behaviors  

    1. Elopement Potential
      1. CHILD- Have they thought about running away?  Do they have a plan?  How many attempts have they made?
      2. ADULT- Any history of elopement?
    2. Suicidal/homicidal ideations:  Have they had any current or past-
      1. Suicidal ideations– any attempts, plans, ideations
      2. Homicidal ideations– any attempts, plans, thoughts?
      3. Click here to read my suicide assessment post
    3. Self harming ideations– any cutting, burning, scratching etc?
    4. Imminent risk of harm:  Are they at risk currently
    5. Urgent needs (Describe any high risk situations, including suicide risk, personal safety and risk to others):
      1. Mental:  Are they currently putting themselves at risk behaviorally or with their choices?
      2. Physical:  Any urgent physical symptoms that need to be addressed?

SOCIAL: Family History….

The biopsychosocial assessment also includes information pertain to the client’s family background, social history, and culture.   The following information is obtained: family of origin, current family, marital status, educational background, career history.   Finally, while not included on the form for my internship, other resources suggest a review of the client’s legal history as well as any offender/victim issues.  While not included on my internship’s form, other resources I’ve found include information on the client’s developmental history physically and educationally.
  1. Family of Origin & Current Family

  2. Demographic and historical information:

    1. CHILD-
      1.  Who are their parents and what are their ages.  
      2. Any siblings and ages?  What is the relationship with these people.  
      3. Marriages and divorces of parents.  
      4. If in foster care you may also include the dynamics of the foster family as well.  
      5. Rules of the house and the consequences if not followed.
    2. ADULT-
      1. Parent’s names and ages (or death dates).  
      2. Siblings and ages.  
      3. Current relationships with family and how it was like growing up.  
      4. Any husbands, boyfriends children and their ages.  
      5. What their relationships with them are like.
      6. Divorces, separations, deaths and incarceration of parents and significant others (include reasons):  Are there any deaths or incarcerations or divorces that are significant?  
  3. Current Significant Relationships

    1. families, friends, community members
    2. Marital Status & Sexual History
  4. Abuse & Trauma History

    1. Witnessed or Experienced
    2. Physical / Sexual / Emotional
    3. Any Neglect or Abuse…
  5. Natural Supports

    1. (Describe if there is a need for supports)
    2. Who do they go to when they have problems or need help
  1. Career & educational background

  2. Educational history

    1. CHILD–
      1. What grade and school are they in?  
      2. How are their grades?  
      3. What is their behavior like?  I
      4. typically go back 2-3 years to establish patterns.
      5. Did they need IEP, special education?  Is it working?
    2. ADULT–
      1. did they graduate HS?  GED?  
      2. Any college?  
      3. Any IEP or special education while in school?
    3. Literacy Level:  Where is their reading level? 
    4. Need for Assistive Technology
    5. Vocational history:  Employer/Wage/Position/etc…
  3. Living Situation & Finances.

    1. Who lives in the home?
    2. Whom do they live with?
    3. Source of Income.
  4. Military History

  5. Legal Problems

    1. (victim/offender status)
    2. Any current charges pending or waiting?
    3. Legal history and results.
  6. Spiritual Background

  7. Cultural Background

BIOLOGICAL: Medical History…

Since medical issues frequently influence one’s mental health it is also important to obtain the client’s medical history.  Information obtained includes a list of the client’s medical issues, prescribed medications, history of hospitalizations and surgeries, as well as their primary physician’s contact information.
  1. Significant Medical history

    1. Co-occurring disabilities?
    2. Urgent physicial symptoms?
    3. Diagnoses?
    4. Hospitalization? Surgery?
  2. Medication List:

    1. Name
    2. Purpose
    3. Dose
    4. Date of Initial Prescription
    5. Frequency
  3. Current Physican

    1. Primary care physicians contact information:  Name of doctor and contact information
    2. Did you request a release to speak with the primary care physician?  Yes
    3. Did you make contact with the primary care physician after initial assessment?  Yes, the appropriate form was mailed/faxed.
  4. Developmental History

    1. to include developmental age factors, motor development and functioning
    2. Have they been (or did they meet) their developmental milestones on time?  
  5. Hearing Functioning: 

    1. How is their hearing?  
    2. Have they ever been tested?  
    3. You can also assess auditory hallucinations here.
  6. Vision Functioning: 

    1. How is their vision?  
    2. Do they wear corrective lenses?  
    3. When was their last eye exam?
  7. Immunization Record

    1. (for children/adolescents –
    2. Are they up to date with immunizations?
  8. Prenatal exposure to alcohol, tobacco, or other substances

  9.  PERSONAL ASSETS AND LIABILITIES

    1. Strengths as described by the client:  What does the client state are their strengths?
    2. Limitations:  What needs to be worked on?
    3. Individual needs and Client-identified areas for improvement and desired outcomes:  
    4. What does the client stated they want to improve in therapy?  

Diagnosis & Diagnostic Impression

  1. Diagnosis – simply the DSM-5 diagnoses listed

  2. Diagnostic Impression:  

    1. This is where you will list out the criteria the client meets for the diagnosis above.  
    2. You need to make sure that the symptoms reported earlier match the criteria.  
    3. In reading an IDI a clinician should already see how you came up with this diagnosis

INTERPRETIVE SUMMARY AND TREATMENT RECOMMENDATIONS

  1. Treatment needs and recommended interventions for client and family: What do you recommend?  Individual, Family, Psychological eval, CD eval, psychiatric eval etc.  

  2. What are the issues that need to be addressed?  Justify why? Due to the nature of John’s symptoms, cognitive behavioral therapy is recommended

  3. Identification of who needs to be involved in the client’s treatment: Who needs to be involved?

  4. Plan to meet needs: What is the plan to meet the needs?  Frequency of sessions?

  5. Evaluation of progress: Progress will be evaluated at intake, quarterly, and discharge using the WHODAS 2.0 12-item interview-administered version.

 

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Mental Status Exam

Utility of MSE

img_2202The Mental Status Exam (MSE) provides a cross-sectional snapshot of a client’s mental state at a particular point in time (Morrison, 2014; Robinson, 2002). Conducted informally, the MSE is routinely conducted as part of an intake interview (Hays, 2013). This tool provides an organized set of observations made during an interview that pertain to “sensorium, perception, thinking, feeling and behavior” (Robinson, 2002, p6).  Since the MSE is designed to provide accurate snapshot of an individual’s mental state at one point in time, its diagnostic utility is limited (Hays, 2013; Morrison, 2014; Robison, 2002). Nonetheless, this tool can help describe abnormalities in an individual’s mental state and present it in an organize manner (Robinson, 2002). It can shed light on “red flags” that require further assessment (Morrison, 2014). As a key component of the intake interview, the MSE, is used frequently during admission to a facility or program. It is also useful when a client first enters therapy to provide an overview of a client’s current condition. When taken alongside collateral information and other assessments this tool can also can aid in treatment planning. In this respect, the MSE is also useful to determine an individual’s response to treatment. Finally, MSE’s are used to monitor a client’s well being in response to serious diagnoses such as schizophrenia (American Psychiatric Association, 2013).

It is a cross-sectional assessment tool.

It is not a substitute for diagnosis.

A primary goal is to note abnormalities that require further analysis.

Provides set of standardized observations to guide evaluation.

Information Gathered in a MSE

As stated earlier, the MSE is designed to gather information on: (1) sensorium and cognitive functioning, (2) perception, (3) thinking, (4) feeling, and (5) behavior (Robinson, 2002). This information is divided and organized into the following areas (Hays, 2013; Morrison, 2014; Robison, 2002):

Appearance

Information gathered regarding an individual’s appearance can include observed physical traits; grooming habits, and attire.   Additionally, it often reveals demographic information on an individual’s age, gender, and cultural background.   How does the patient look?   My textbooks describe three areas of observation to note here, (Hays, 2013; Morrison, 2014).

  1. GENERAL APPEARANCE:  “information concerning general appearance should be evidence [available to] the unpracticed eye, (Morrison, 2014, p. 119).”
  2. LEVEL OF ATTENTION: How alert is the patient?  Are they hypervigilant?  Are they drowsy & inattentive?
  3. LEVEL OF ACTIVITY:  The patient’s level of activity can be an indicator of diagnosis.  Observations can include level of motor activity, tarditive diskinesia, purposefulness of movement, tremor, etc.
  4. BEHAVIOR:  Is the client pleasant, cooperative, agitated?  Is their behavior appropriate given the current situation?   Observe mannerisms, expression, eye contact, ability to follow commands.
  5. ATTITUDE:  Cooperative, hostile, open, secretive, etc…

Mood & Affect

Morrison, (2014), describes “mood as how we feel, and affect as how we appear to feel” (p122). Observations on affect can include variations in quality, range, appropriateness and degree of reactivity (Robinson, 2002). Notable factors regarding a client’s mood can include reports of feeling states that predominate most often. Finally, the level of congruency between affect and mood is also notable symptom.

  1. MOOD:  “The client’s self-reported feeling, (Hays, 2013, p. 124).”   Assessed via inquiry: how are you feeling?
  2. AFFECT:  “External expression of emotional state, (Hays, 2013, p. 124).”
  3. QUALITIES OF MOOD & AFFECT:
    1. TYPE:  exactly what is the client feeling: Sad, Happy, etc??
    2. LABILITY:  How uncontrollable are their emotional displays??
    3. APPROPRIATENESS:  Is there a congruency between thoughts and emotions???

Speech & Language

Speech reflects an individual’s verbal expression and can vary greatly in fluency, quality, rate and flow (Morrison, 2014; Robinson, 2002). Language refers to the communication of ideas and can be described in terms of the meaning it contains and quality of articulation (Morrison, 2014; Robinson, 2002).

  1. QUALITIES OF SPEECH:
    1. FLUENCY: initiation & flow of speech (Hays, 2014, p. 124).”
    2. REPETITION:  repeating words or phrases (Hays, 2014, p. 124).”
    3. COMPREHENSION: Understanding of spoken/written commands (Hays, 3014, p. 124).”
    4. PROSODY:  Attention to tone, rate, rhythm, (Hays, 2014, p. 124).”
    5. QUANTITY, RATE, VOLUME, FLUENCY, & RHYTHM.
  2. DIAGNOSTIC EXAMPLES FROM MORRISON (2013).
    1. CIRCUMSTANTIAL SPEECH:  indicates nonlinear thought pattern.
    2. DERAILMENT:  speech incoherent where ideas are loosely associated or unrelated.
    3. NEOLOGISM, ECHOLALIA, & INCOHERENCE.

Sensorium & Cognition

Sensorium refers to the brains ability to intake and process information from the senses.  Sensorium also refers to an individual’s level of consciousness overall.  In contrast, cognition refers to the processes of logic, reason, memory, abstract reasoning and intellect (Hays, 2013). Robinson, (2002) adds that cognitive function assessments also assess for level of alertness and orientation in addition the one’s degree of attention and concentration. While these factors frequently reflect one’s level of education d native intelligence, they can also indicate the presence of a functional deficit (Morrison, 2014).

  1. LEVEL OF CONSCIOUSNESS:  LOC refers to the level of wakefulness.  Is the patient conscious, if not can you arouse them?  Are they able to maintain focus on the conversation?
  2. ORIENTATION: Is the client oriented to time, place and person?
  3. ATTENTION & CONCENTRATION:  Is inquired & observed.  How distractable are they?  Assessments involve evaluating how well clients attend and concentrate during an assigned task.
  4. MEMORY: How effective is the client’s ability to recall short term and long term information?
  5. INTELLIGENCE:  Intelligence is the ability to acquire and apply knowledge.  It includes both observed and inquired information.
  6. ABSTRACT THINKING: this refers to an ability to grasp facts that are not concrete and removed from the “here and now”.

Thought & Perception

An assessment of thought and perception is garnered through inquiry via the intake interview.  Perception is a reflection of how the brain interprets sensory input (Robinson, 2002). Hallucinations and illusions are just two examples of perceptive symptoms. In contrast, thought content and process assess what garners the focus of an individual’s mind (Robinson, 2002). For example, thought content focuses on what an individual is thinking about, and can include symptoms of obsession, phobia, and delusion (Hays, 2013; Morrison, 2014; Robison, 2002). In contrast, thought process refers to the clarity and organization of our thinking (Robinson, 2002).

  1. THOUGHT CONTENT:  Thought content refers to what the client is actually thinking about. Examples include the following:
    1. SUICIDAL &/OR HOMICIDAL IDEATION
    2. DELUSIONS:  (i.e. paranoia, etc).
  2. THOUGHT PROCESS: Thought process refers to the clients manner of thinking…observations include “clarity of communication, association, & connectedness between topics (Hays, 2014, p. 124).”    Examples include the following:
    1. highly irrelevant comments (loose associations or derailment)
    2. frequent changes of topic (flight of ideas or tangential thinking)
    3. excessive vagueness (circumstantial thinking)
    4. nonsense words (or word salad)
    5. pressured or halted speech (thought racing or blocking)
  3. PERCEPTION: An assessment of perception examines abnormalities in how a person interprets sensory information, (Hays, 2014).  Disorders of perception can include the following:
    1. DEPERSONALIZATION/DISSOCIATION: altered bodily experience (Robinson, 2002).
    2. HALLUCINATION:  Perception of sensory input when no stimuli present (Robinson, 2002).
    3. ILLUSION:  Misperception of stimuli, (Robinson, 2002).

Insight & Judgment

Insight refers not only to an awareness of reality, but also to the degree of self-knowledge we possess regarding how we influence our world (Hays, 2013; Robinson, 2002). Judgment is defined in one’s decision-making abilities and how this is reflected in our actions (Morrison, 2014).

  1. INSIGHT:  An assessment of insight can include the clients level of acknowledgement regarding issues they currently struggle with and willingness to comply with treatment
  2. JUDGMENT: Assessing a client’s problem solving ability can include utilizing a hypothetical scenarios and asking what they might do.

ABC STAMP LICKER

Robinson (2002) provides the following as a way of remembering the main areas to assess during a mental status exam, “ABC STAMP LICKER”

Appearance
Behaviour
Cooperation

Speech
Thought content & form
Affect
Mood
Perceptions

LOC / Orientation
Insight & Judgement
Cognitive function & Sensorium
Knowledge
Ends (suicide/homicide)
Reliability

For more information read THIS or THIS, or THIS

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Hays, D.G. (2013). Assessment in counseling a guide to the use of psychological assessment procedures (5th Ed.). Belmont, CA: Brooks/Cole, Sengage Learning.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental leather clinicians, 2nd ed. New York: The Guildford Press.
Robinson, D (2002). Mental Status Exam Explained, 2nd ed. Rapid Psychler.

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Suicide Assessment

Junke, et al, (2007) state that suicide is the 11th leading cause of death amongst Americans. Hays, (2013) also mentions that approximately 40% of the general population have “had periods of suicidal thinking at some point in their lives” (p130). With this in mind, an understanding of common suicide assessment tools is vital for the student therapist. Establishing a rapport is essential in order to begin discussing an individual’s suicidal thoughts in an honest manner (Hays, 2013). This also ensures greater accuracy in suicidal risk assessments (Hays, 2013). A direct and calm approach provides the client an opportunity to discuss this behavior in a safe environment. Hays, (2013) states that a thorough suicidal risk assessment should consider all of the following elements:

Self-Reported Risk Level – In clients who acknowledge suicidal ideation, it is important to obtain the client’s self-reported level of risk. As stated earlier, in order to ensure the accuracy of a suicidal risk assessment, it is important to first establish a rapport with the client. The client needs to feel they are in a safe and empathetic environment when discussing this issue.
Suicide Plan – Hays (2013) states, “the best indicators of suicidal risk are ideation, plan, intent and means” (p.131). With this in mind, counselors need to ask the client if they have developed a suicidal plan. Risk increases when clients have plans ironed out in detail, and are able to access their preferred means of suicide (Hays, 2013).
Suicidal History – Counselors should assess for a personal and familial history of suicide attempts and/or threats (Hays, 2013).
Psychological Symptoms – Hays, (2013) states that suicidal ideation correlates with long-standing symptoms of distress, depression, hopelessness, and difficulty sleeping (p132). Additionally, mental disorder diagnoses and substance use history greatly increases a persons’ risk for suicide. Hays (2013) states that 90% of those who commit suicide have a mental diagnosis, and alcohol abuse increases an individual’s risk for suicide by 50-70% (p.132) .
Environmental Stressors – Stressful situations such as an impending divorce and the loss of a loved one, can increase an individual’s suicide risk (Hays, 2013).
Support System – A suicide risk assessment should include a review of an individual’s social network, and support system (Hays, 2013).

With this information in mind, it is now possible to begin comparing five suicide assessment tools for this assignment. The key elements of a suicide assessment described above, will be used as a point of comparison while discussing these tools.

Military Suicide Risk Assessment Guide (DHCC Clinicians, 2003)

Information Provided

Risk Factors. This tool begins with a review of factors that increase an individual’s suicide risk (DHCC Clinicians, 2003). In addition to listing common socio-demographic risk factors, this tool provides an overview of common life stressors and mental health diagnoses associated with suicide (DHCC Clinicians, 2003).
Assessment Questions. In an effort to guide the assessment process, this tool states: “suicide risk increases with a specific plan, positive means, strong intent, low likelihood of rescue…[and] a positive history of previous attempts” (DHCC Clinicians, 2003). In light of this fact, this tool provides a list of question that assesses an individual’s suicidal plan, previous history, as well as protective factors (DHCC Clinicians, 2003).
Treatment Recommendations. This tool very briefly provides a list of suggestions depending on whether the patient meets high suicide risk criteria. For example, this tool encourages the counselor to remain with the patient who meet high-risk criteria and make arrangements for transfer into hospital setting for further evaluation (DHCC Clinician2003).
“SAD PERSONS” Mnemonic Overview. The final page of this tool provides a brief overview of suicide risk factors in an easy-to-remember mnemonic “SAD PERSONS”. While this information is duplicative, it provides as an easy-to-remember review of key suicide risk factors discussed previously.

Information Missing

No information is missing in accordance with Hay’s list of suicide risk assessment factors (Hays, 2013). However, this tool only provides a brief overview of the suicide risk assessment process. In this respect, it is most useful as a quick guide rather than an in-depth reference source.

Suicide Assessment Mnemonic #1: “IS PATH WARM?” (Junke, et al, 2007)

Information Provided

The next suicide risk assessment tool reviewed for this assignment is an article published by the American Counseling Association. After providing an overview of statistics on various suicide rates, this article discusses a new suicide risk factor mnemonic: “IS PATH WARM?” (Junke, et al, 2007). “Each letter corresponds with a risk factor noted as frequently experienced and reported within the last few months before suicide” (Junke, et al, 2007). The specific risk factors listed in this mnemonic include: (1) suicidal ideation, (2) substance abuse, (3) anger, (4) trapped feelings, (5) hopelessness, (6) anxiety, (7) recklessness, & (8) mood (Junke, et al, 2007).

Junke, et al (2007), note that the presence of these factors signifies a warning that more thorough suicide assessments are necessary. In this respect, this tool is simply a means of augmenting a therapist’s clinical judgment by shedding light on key risk factors associated with suicide ideation.

Information Missing

This suicide risk factor mnemonic serves the purpose of indicating key suicide risk factors in an individual’s history. It is not intended for use as a thorough suicide assessment guide and includes no information on an individual’s suicide plans, environmental stressors, psychological symptoms, suicide history, or protective symptoms (Junke, et al, 2007).

Suicide Assessment Mnemonic #2: “SAD PERSONS” (Unknown, 2015a)

Information Provided

The next assessment tool reviewed for this assignment is an article that discusses another suicide risk factor mnemonic: “SAD PERSONS” (Unknown, 2015a). As with the previously mentioned mnemonic, this tool is useful in assessing suicidal risk factors that indicate the need of more in depth assessments. The risk factors associated with this “SAD PERSONS” mnemonic include the following:

Sex & Age – Males are more likely to commit suicide and individuals ranging from 15-24 years of age are at elevated risk (Unknown, 2015a).
Depression – Clinically depressed individuals are 20 times more likely to commit suicide (Unknown, 2015a).
Prior History of Suicide & Alcohol Abuse – Substance use increases an individual’s risk for suicide and 80% of completed suicide occur in individuals with a previous history of suicide (Unknown, 2015a).
Rational Thinking Loss – Symptoms of psychosis are associated with a higher risk of suicide (Unknown, 2015a).
Inadequate Support System – The loss of a valuable support system is associated with a higher risk of suicide. Death and divorce are common examples of this sort of loss.
Illness – Terminal illness is associated with a “20 fold increase risk of suicide” (Unknown, 2015a).
Organized Suicide Plan – A detailed plan, that encompasses access to a means of killing oneself, greatly increases risk for suicide in the individual (Unknown, 2015a).

Information Missing

As noted earlier, the purpose of this tool is assessing for key risk factors associated with a heightened risk for suicide. Unlike the previous mnemonic tool, this one provides a scoring system with treatment suggestions to guide therapist’s clinical judgments. This tool does not address the elements of a suicide risk assessment listed in our Hays (2013) textbook. Instead it exists as a precursor to this process and helps indicate if more thorough assessments are required.

Suicide Risk Assessment Interview Form (Unknown, 2015b)

The next suicide assessment tool reviewed for this assignment is an interview form (Unknown, 2015b). It includes all information essential in a suicide risk assessment indicated in our Hays, (2013) textbook. Additionally, this tool provides guidance throughout the process by outlining the steps in assessing suicidal risk (Unknown, 2015b).

Information Provided

Self-Reported Risk Level The Suicide Risk Assessment Interview (Unknown, 2015b) begins with an assessment of the patient’s safety. This involves determining if the client has access to a weapon and if they are able to remain safe throughout the assessment. The form also asks individuals to describe the circumstances and relevant details associated with their suicidal thoughts.
Suicidal Plan – Hays (2013) states that “the best indicators of suicidal risk are ideation, plan, intent and means” (p.131). With this fact in mind, this tool includes questions to thoroughly addresses all of these elements in an individual’s suicide plan (Unknown, 2015b).
Protective Symptoms – This Suicide Risk Assessment Interview Form asks about an individual’s coping skills and support system (Unknown, 2015b). These questions are indicative of protective factors that reduce one’s risk for suicide
Complete History – This tool includes information on an individuals past suicidal history (Unknown, 2015b). It also addresses an individual’s medical background and past history of substance use (Unknown, 2015b).
Environmental Stressors – This tool also assesses an individual’s cultural background and the presence of relevant life stressors (Unknown, 2015b).
Psychological Symptoms – An array of psychological symptoms associated with suicide risk are assessed in this tool. (Unknown, 2015b). For example, in addition to assessing symptoms of psychosis, and depression, it provides information behavioral cues indicative of heighted suicide risk (Unknown, 2015b).

Recommended Assessment Steps

  1. STEP ONE: “Conduct a thorough assessment” (Unknown, 2015b). Information should be gathered on the client’s past medical and psychiatric history. In addition to assessing the patients current symptoms, other information should be gathered such as the patient’s sociocultural background and coping skills (Unknown, 2015b).
  2. STEP TWO: “Specifically inquire about suicide” (Unknown, 2015b). – While not all individuals are ready to discuss their suicidal thoughts, an open and honest discussion about any suicidal ideations is vital (Unknown, 2015b).
  3. STEP THREE: “Determine the extent of suicidal ideation” (Unknown, 2015b). The next step in the suicidal risk assessment process includes a determination of the extent and pervasiveness of any suicidal intentions (Unknown, 2015b).
  4. STEP FOUR: “Assess lethality and determine risk level” (Unknown, 2015b). Step four involves assessing an individual’s suicide plan. This includes a determining the plan’s level of lethality as well as the extent of an individual’s access to means of suicide (Unknown, 2015b).
  5. STEP 5 & 6 : The final two steps of a suicidal risk assessment include determining if a safety plan exists and developing one as necessary to ensure a patient’s safety (Unknown, 2015b).

APA Practice Guidelines for Assessing Suicidal Behavior (Jacobs & Brewer, 2004)

The last suicide assessment tool reviewed for this assignment includes an article published by the American Psychiatric Association. This article provides an overview of the APA “Guidelines for Assessment & Treatment of Patients with Suicidal Behaviors” (Jacobs & Brewer, 2004, p373). This resource doesn’t include the specific steps listed in the above Suicide Risk Assessment Interview (Unknown, 2015b). Nonetheless, it is still the most comprehensive tool on assessing suicidal patients. While much of the information in this tool is a reiteration of information discussed previously, it is addressed in a much more thorough manner (Jacobs & Brewer, 2004). This tool provides guidance for therapists throughout the suicide risk assessment process (Jacobs & Brewer, 2004). For example, this article discusses in greater depth, characteristics to evaluate in a suicide assessment including: (1) current suicidality, (2) Past Suicide History, (3) Psychiatric Illnesses, (4) Psychosocial Factors, and (5) coping skills (Jacobs & Brewer, 2004). It also provides guidelines to determine the appropriate safety measures and treatment setting relevant to a specific case (Jacobs & Brewer, 2004). In this respect, it goes well beyond the other tools. Not only does it discuss what information one needs to gather, it provides detailed insight on what to do with this information. This insight is critical for beginning therapists who are working to develop their own clinical judgment.

Concluding Remarks

The Military Suicide Risk Assessment Tool is useful in providing an overview of the Suicide Assessment Process (DHCC Clinicians, 2003). The Mnemonic Risk Assessment Tools are used to indicate if key suicide risk factors are present in an individual’s history (Junke, et al, 2007; Unknown, 2015a). This is useful in determining if a more thorough suicide risk assessment is necessary history (Junke, et al, 2007; Unknown, 2015a). In contrast, the Interview Form (Unknown, 2015b) and APA Practice Guidelines, (Jacobs & Brewer, 2004), provide a thorough review of the suicide risk assessment process. The Interview Form provides a set of topics to address with steps to guide the assessment process (Unknown, 2015b). The APA Practice Guidelines provide insight on how to utilize the information once it has been gathered. This tool can guide clinical judgment in determining the level of care and safety measures required for a particular case (Jacobs & Brewer, 2004).

Click here to read the story of my (almost) suicide”

References

DHCC Clinicians (2003). Military suicide risk assessment: Primary care clinic visit guidance.
Retrieved from: http://www.pdhealth.mil/guidelines/downloads/Suicide_Screening.pdf

Hays, D.G. (2013). Assessment in counseling a guide to the use of psychological
assessment procedures
(5th Ed.). Belmont, CA: Brooks/Cole, Sengage Learning.

Jacobs, D., & Brewer, M. (2004). APA practice guideline. Psychiatric Annals, 34(5), 373-380

Junke, G; Granello, P., & Lebron-Striker, M. (2007). IS PATH WARM?: A suicide assessment
mnemonic for counselors.
American Counseling Association. Retrieved from: 
https://www.counseling.org/docs/default-source/library-archives/professional-counselor-digest/acapcd-03.pdf?sfvrsn=6

Unknown (2015a). Suicide assessment: SAD PERSONS. Retrieved from: http://www.capefearpsych.org/documents/SADPERSONS-suiciderisk.pdf

Unknown (2015b). Suicide risk assessment: Interview form. Retrieved from:
suicidal risk assessment.doc

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