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)
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.
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)
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.
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)
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).
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).
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
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).
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).
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).
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).
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.
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).
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