Streamlined Suicide Assessment & Safety Planning

Editor's Note: This text-based course is a transcript of the webinar, Streamlined Suicide Assessment & Safety Planning, presented by Khara Croswaite Brindle, MA, LPC, ACS, CFT-I.

Learning Outcomes

• After this course, participants will be able to identify and explore the interaction between risk and protective factors when engaging a person at risk in a formal suicide assessment.
• After this course, participants will be able to identify engagement strategies for a person at risk in suicide assessment and safety planning to support symptom management.
• After this course, participants will be able to analyze a case study for application of suicide assessment and safety planning clinical steps.

Limitations/Risks

• Limitations include ongoing suicide prevention research additions impacting the relevance of the materials presented. A second limitation is that the current research reflects the white majority. Additionally, limitations of religious context can serve as a barrier to open dialogue around suicide.
• Risks include 1) clinician discomfort or lived experience with suicide and 2) Imposed subjective perspective.

I am excited to be here. This will be a lot of content, and hopefully, this will feel very relevant and empowering for all of you. 

Limitations include that ongoing suicide prevention research additions are impacting the relevance of the material presented. In other words, we are always learning something new about suicide assessment and risk. We want to ensure our information is updated, but we recognize that it changes constantly. A second limitation is that the current research reflects the white majority. Additionally, limitations of religious context can serve as a barrier to open dialogue around suicide. 

Risks include clinician discomfort or lived experience with suicide and imposed subjective perspective. In other words, this topic is heavy. I want to respect that for everyone. 

Introductions

• Lived Experience
• Professional Experience

I am talking to you about this topic because I have lived experience of suicide, like many of you who are taking this course. Several family members died by suicide before I was 18 years old. This shaped my family and professional life and why I became a counselor and a licensed professional therapist. It has been a passion of mine to talk about suicide with clinicians since 2017. I wanted to ensure clinicians had the strategies and tools to help clients.

Our Client

Throughout the presentation, here is the image I want you to think of for our case study.

Figure 1. Image of a sad woman for the case study.

For today, the case study is a 27-year-old female named Daphne. You have done an intake, another two sessions, and now you see her for a third session. As we can see in this image, she does not feel very well. There may be some questions you have for Daphne as we go forward and assess her for suicide. 

Suicide Response

• Suicide Assessment
• Crisis Response
• Verbal Contracts
• Safety Planning
• Referrals and Resources

As mental health professionals, there are several different suicide responses. Suicide assessment is where we will spend most of our time in today's presentation.

Another thing to note would be crisis response. What crisis response is available in your area? This is everything from a mobile crisis to a stabilization unit. Is there a specific mental health walk-in clinic that folks can go to that is a little more appropriate for suicidal thoughts than an ER? Is the local ER easily accessible for your clients? Knowing all those options can be valuable to you as a mental health professional.

I want to stir the pot by asking about verbal contracts. Verbal contracts were popular in the '80s and '90s; however, they were not effective. For example, verbal contracts have clients agreeing not to kill themselves within the next 24 hours. As a clinician, we would ask them to have a contract for safety. Unfortunately, the research shows that the contract does not prevent them from that attempt. Instead, it was just giving clinicians peace of mind. Verbal contracts do not save lives. Some of you were trained in contracts, but the data does not support them.

Instead, we want to focus on safety planning, a part of today's training. Safety planning is meant to be a collaborative empowerment tool to help the client figure out what can be done first, second, and third to help them feel safe before a suicide attempt is made. We are going to talk about those working components of a safety plan.

We must know the referrals and resources in your area. What are the higher levels of care and resources? The Suicide and Crisis Hotline is 988. There may also be a local hotline or a text line. 

As we talked about with risk, we all have our stuff that shows up with suicide. We may have lived or professional experiences with suicide, and this matters. The American Association of Suicidology says that each death by suicide impacts a minimum of 135 people. When we think about highly publicized suicides, we can see how the impact grows exponentially. Additionally, the data shows us that 25% of mental health professionals at the master's level will have a client die by suicide somewhere in their career.

This topic is relevant to all of us, and it feels a little heavy knowing that 25% of us will experience that. The fact that you are here is because you hope there is something you can do to save lives. With that being said, let's talk about engagement.

Engagement

• Space
• Mannerisms
• Tone
• How to ask the question

For engaging the client, there are things I want you to keep in mind. What space are you discussing suicide? Are you working in a community mental health center or a school? Knowing the space for confidentiality and safety helps the client either open up about their suicide story or stay clammed up. We want to have a safe space. Additionally, we want to consider the space in terms of lighting, exits/doors, and furniture. For example, is there a coffee table or something in between you that would be considered a physical barrier? 

How do you show up as a mental health professional in the room? What are your mannerisms when it comes to asking about suicide? For example, if you are asking about suicide with raised shoulders or a concerned look on your face, this might not encourage a client to share or disclose what is going on. You may think you are comfortable talking about suicide, but your body is saying something else. Are you recoiling, closed off, or have a protective pillow in front of you? These things are worth noting, just like we would note with a client.

We also want to pay attention to our tone. What is your tone of voice? You do not want to say, "You're not thinking of suicide, are you?" We want to normalize it by saying, "Other clients I have worked with have had this experience which has led them to some suicidal thoughts. Is that part of your experience?" Having a very warm tone without judgment, criticism, or shame is crucial. We also do not want to use double negatives. 

How do you even ask the question? One popular way is, "Are you thinking of hurting yourself?" The problem with that question is that many are concrete thinkers, especially teenagers and young adults. They might say, "No, I'm not thinking of hurting myself," but they are thinking of dying by suicide. They may think "hurt" versus suicide is two completely different things. Instead of circling the question, we want to directly state, "Are you thinking of suicide or having suicidal thoughts?" We want to ensure that the client truly understands what we are asking so that we can get a clear picture of their suicide story.

Returning to our client Daphne, we want to ask, "Are you thinking of suicide?" Practicing those direct questions is the first tip of this training.

Suicide Assessment

• A  Ask: Suicide Inquiry
• L  Listen: Risk Factors
• E  Engage: Protective Factors
• R  Respond: Safety Measures & Intervention/Plan
• T  Tasks: Next Steps/Documentation

As we move forward, I will break down suicide assessment into this ALERT acronym that I have used since 2017. "A" is for ask and the elements of a suicide inquiry or suicide story, which is the other way to label it. Listen is "L," which are the risk factors, and there are dozens. "E" is for engage and protective factors. You want to know what is keeping them alive. "R" is for respond, including safety measures and intervention/plans. Tasks are "T" because if we do not document them, it does not happen. We want to ensure that this is all reflected in the suicide assessment process.

Ask: Suicide Inquiry

• Direct Questions
• Frequency/Controllability/Duration
• Visual/Imagery
• Personal Meaning

(Freedenthal, S., 2018)

Ask is the suicide inquiry, and we already discussed using direct questions. We are not asking if they will hurt themself; we are asking directly about suicidal intent. Some trainings have clinicians practice this repeatedly until they are more comfortable with this question. By no means do we expect someone to be comfortable with this from the get-go unless you have had a lot of experience or training. We can still have a lot of compassion while asking questions.

Other things to ask as we start the conversation on suicide are frequency, controllability, and duration. How often are they having suicidal thoughts? They may say every moment, every day, or only when they were a teenager. Controllability is how easy or difficult it is to control suicidal thoughts. One person's response, "It's easy to control. I just push it out of my mind. I'm fine," feels very different than someone saying, "I can't control it at all as it's constant." Finally, duration is how long it lasts. Are the suicidal thoughts fleeting or every day, with no respite? As a clinician, we assess their suicidal risk based on the answer to these three questions.

Additionally, we want to ask about the visual or imagery, which is a more modern question in suicide assessment. When you think about suicide, what do you see? For the youngest generations, this is a compelling question. It could add a lot of context to what is going on for them. Perhaps the visual is that they see themselves at peace and are no longer tortured by something. They may see themselves reunited with a loved one. Maybe all of the stressors are gone, and they feel more relaxed. For someone else, it might be blank or blackness, which does not add a lot of context, but it does help us sit in the suicide story. We are showing the client that we are comfortable being here and having this conversation.

Lastly, personal meaning. When they think about suicide, what does this mean to them? Many times, you are going to hear, "This will bring me peace," "I'll no longer be tortured," or "I'll no longer be in pain." Suicide research shows that people who die by suicide are not focused on the death component but are thinking about inescapable pain, which increases suicidal risk. Looking at the personal meaning and the visual imagery is a critical component of what to ask.

• Suicidal Thoughts
  • Exposure to Suicide
  • Plan/Preparatory Acts
  • Lethality of Plan
  • Rehearsal
  • Intent

(Flemons, D., & Gralnik, L., 2013)

We need to talk about suicidal thoughts as it gives us more information about their context. It might surprise you, or maybe not, that 10.3 million people have had suicidal thoughts. This is an experience for many people so just having a suicidal thought is not enough to determine risk. Suicidal thought is part of the human experience. It is the thought of driving down a windy road and wondering what it would be like to lose control and fall off the side of a cliff. On a lighter note, it also can be a life phenomenon to think about what it would be like if I never existed or I was never born. Asking about suicidal thoughts here and now are helpful, but we need to go a little deeper than that.

What is their exposure to suicide? Are they suicide loss survivors with family members who have died by suicide or been exposed in their community? Exposure matters and will change the risk level for a client.

We also want to know if they have a plan. If they have a plan, what preparation or preparatory acts have they done? Maybe their goal is to stop eating, which feels like a different level of risk than someone who says, "I have a loaded firearm in the back of my car." What are their preparatory acts? They may have bought a firearm, gathered pills, or Googled how to tie a noose. These are things that a client might tell you if they feel safe.

Based on that plan, what is the lethality? The lethality of a firearm is pretty high. It sounds crass, but it is hard to mess that up or to miss. As such, guns continue to be the most lethal means of suicide. It is very different from someone who takes pills or tries hanging themselves.

Have they rehearsed their suicide plan, such as loading the firearm, tying the noose, putting it around their neck, or visiting a place where they want to die? For example, some of you are familiar with Kevin Hines' work, who is a world speaker on suicide prevention. When Kevin was young, he suffered from many different things, including decreased mental health, and he decided he did not want to live any longer. Part of his rehearsal was visiting the Golden Gate Bridge several times before he made his attempt. In his documentary, which is popular now, he says he got on a bus and decided he wanted to die. Part of his rehearsal was, "I'm here going through the motions, but if one person asks me if I'm okay, I won't go through with it." I am sure you are all hoping for a happy ending to this story, which is that someone saw him visibly upset and said, "Are you okay?" Unfortunately, that was not Kevin's experience. He went through the whole bus ride with no one asking, even though he was visibly upset, with tears falling down his cheeks. He got to the Golden Gate Bridge and decided, "This is the last chance for someone to ask if I'm okay." When he heard someone say, "Excuse me," he thought, "Good, someone's finally going to ask me, 'Are you okay?'" Instead, they asked, "Will you take my picture?" This question makes sense as it is a tourist trap, but it is still very painful. He takes the picture and then launches himself over the side of the bridge. Falling at 75 miles an hour, he breaks his back and survives. Since then, he has become a national speaker about suicide. As soon as his feet left that bridge, he realized he did not want to die but wanted the pain to stop. This story reinforces how suicide is about an inescapable pain more than it is about death.

When we think about intent, this is where a lot of clinicians have some gray areas regarding self-harming behaviors. It may or may not surprise you that suicide is one of nine reasons for self-harm. There is no cause-and-effect relationship between self-harm and suicide. We need to ask about intent. What was your intention for doing this behavior? What was your intention for scratching your arm, burning your arm, or doing other self-harming behaviors? Be upfront and direct with those questions.

As we take in the information about the ask, let's think about Daphne, our 27-year-old female client. She looked distressed, sad, and closed off in the third session. Imagine she is curled up in your chair or couch in your office. She is not making eye contact, and your gut says, "I need to figure out what is going on." You are going to ask Daphne a direct question about suicide. You want to know the context to see if something has happened. Let's assume that Daphne is telling you that she has ended a committed relationship recently, is struggling in her workplace, and her parents are getting a divorce. These are significant stressors. 

Listen: Risk Factors

• Suicidal Behaviors
• Current/Past Mental Health Disorders
• Symptoms

(Joiner, T., 2005)

As we move on to L for listen, there are a lot of risk factors. There is no cause-and-effect relationship where one risk factor equals suicide. If that were the case, this training would be over. Instead, we need to look at all those risk factors and how they interplay to say, "This is a cause for concern." There are certain signs.

Suicidal behaviors are the first one. Maybe this is the first time they have had a suicidal thought, and perhaps it is not. Have they had previous suicide attempts, plans, or thoughts? These are things to ask them.

You also want to know if they have any current or past mental health diagnoses. Any mental health diagnosis puts someone at greater risk for suicide. If they have a formal diagnosis, something is causing dysfunction or disruption to their life. It has to be significant enough to have a diagnosis. It might feel inescapable and painful and is part of the person's experience. That said, there are five mental health diagnoses at the top end of high risk for suicide. Number one is depression. The media latches onto depression and tries to say depression equals suicide, which we know is not that simple. It is much more complex than that. Number two is PTSD, three is substance use, four is bipolar disorder, and five is a borderline personality disorder. When you think about those top five, there is some overlap in those five diagnoses and things like disruptive sleep, insomnia, and hypersomnia when you think of depression. They may think, "This my third or fourth bout of depression in my lifetime," which may feel heavy. Things like loss of appetite, weight gain, and loss of pleasure are common with these five.

Additionally, people speak most freely about symptoms to mental health professionals and their doctors. They may say they feel lethargic or anxious or they cannot sleep. They might be verbally saying all of that, but the health professionals are not making the connection to suicide, which has been a problem in our mental health and medical arenas. This also contributes to the risks of folks that have gone to the ER or their doctor and then, within 30 days, have died by suicide. It is a small subset of people, but it comes from missed symptoms or missed opportunities to connect it back to suicide. Some people are dying by suicide because they feel like going to the ER or doctor was their last-ditch effort to get relief, to get a pill, or to have something change. The good news is that we recognize this from the data and are now trying to be more forthcoming with doctors and using screening tools in an intake. We are trying to reduce the risk of suicide as part of a 30-day turnaround for someone saying, "I need support" or "I need help."

• Other Risk Factors
  • Family History
  • Access to Firearms
  • Physical Illness
  • Lack of Social Connection/Support
  • Psychiatric Hospitalization

(Jointer, T., 2005)

Other risk factors include having a family history or being a suicide loss survivor. I was surprised that I was automatically put in a higher risk category just because my family members died by suicide. Yet, it is a factor. There are two components as to why this is a thing. The first of which is now it has been modeled as okay to die by suicide or that it is an option. The other factor is people who are very close to that family member might want to feel reunited or reconnected with them based on their spiritual beliefs. To die by suicide might feel like a justified response.

Access to firearms, as we mentioned, is the highest lethality regarding a suicide plan. People who have access to weapons and have the impulse to die by suicide scare mental health professionals. There is not much we can do when the firearm is easily accessible. We are advised to help clients to safety plan around a firearm. Reducing the risk may include having them hand the firearm to a trusted friend or family member, secure it in a gun safe, or move the ammunition. We are trying to deter people from having loaded firearms on their nightstands. Right now, if the client is not willing to surrender the firearm to a family member or friend, the best practice is to encourage them to store the ammunition separately from the firearm to reduce the impulsivity component. If we remove the firearm, they do not get creative and use a different means. Most people have been thinking about this for a while, even months or years. Reducing access to a firearm or ammunition can be part of an effective safety plan for folks. Police departments will no longer take people's firearms to hold them, so we must encourage them to find a trusty family member or friend.

Physical illness is also part of our risk factor combination due to inescapable pain. If we have someone with chronic pain or a terminal illness, suicide might show up as a possibility. Physical illness may feel like it will never change and puts the person at high risk for suicide.

Additionally, for our youngest populations, we're hearing a lot more about lack of social connection and support as a risk factor for suicide. Statements like, "No one would notice I'm gone," "People would be happier if I was away," or "I'd be less of a burden on my family" are statements you might hear. The statement that people would not notice they were gone is heartbreaking when you think of a teenager or a young person saying this with conviction and believing it to be true. They are saying they feel disconnected and that people do not care about them.

Lastly, psychiatric hospitalization is a factor. We want to make sure that we reflect on how often they are psychiatrically hospitalized and the impact on their functioning. For some folks, there is a disconnect between how they function at home versus the hospital experience. Maybe the hospital was supportive, and they got their needs met, but then they came back out, and nothing changed in their home environment. Perhaps they changed their medications, which now makes them more at risk for suicide because they have more energy to make an attempt. This is why many hospitals try to secure a visit with you, if they know you exist, to ensure that the client is seen within 24 hours of discharge. In those 24 hours, a client is most at risk for suicide.

Let's think about Daphne for a moment. Daphne tells you that in addition to her stressors (parents getting a divorce, struggling in the workplace, and ending a long-term relationship), she has an uncle who died by suicide. She does not have access to firearms. She is also physically healthy at 27 but feels disconnected without much social support. 

Engage: Stressors

• Work
• Home
• Relationships
• Financial

(Flemons, D., & Gralnik, L., 2013)

As we move to E of the ALERT acronym, we need to engage folks around stressors. Everything we have discussed so far in the ask and listen categories can be present in a person, and they may not be at risk for suicide. Plenty of people function with all those stressors and not be at risk of suicide until something is added, like more stressors or changes. For example, maybe a stressor is around work. Did they get laid off or passed up for promotion? Are they struggling with toxic workplaces and burnout? 

At home, are they feeling supported, or are they isolated? Are they struggling with someone's addiction at home? Or do they feel like they are a burden? We start hearing these things from clients when it comes to suicide.

Relationally, what is going on in their relationships? Do they feel supported there, or is it part of their stress? Is there domestic violence? Is there a financial hardship? We see this with people when there are stock market losses. They may feel like they have lost everything, and suicide becomes possible with someone impulsive and a fast burn versus a slow burn client.

We want to feel like we can have an intervention or do something about these stressors, but it depends on what is happening. I highlight stressors for teenagers specifically because community members will say, "They seemed so happy and put together," or "They are an A student and going to college." Then something in the stressor category happens, and they die by suicide the next day. They may experience a loss, a relationship breakup, or not get into a particular school. All sorts of stressors may contribute to suicide risk for a young person.

• Latest research
  • Veterans
  • GLBTQ
  • Burden
  • Isolation
  • Capacity to complete suicide (Joiner, 2005)
  • Technology Use

(Alter, A., 2018, Joiner, T., 2005, Twenge, J., 2017)

Something else to highlight in the E for engage is the latest research. Research changes all the time, but at this moment, there are some categories or risk groups worth naming as part of the suicide assessment presentation. Veterans continue to be an at-risk group for suicide. Part of that is the capacity to complete suicide, which is Dr. Thomas Joiner's work, and it is the second to last bullet point on this slide. When you look at Dr. Joiner's work, I want you to imagine a Venn diagram with three intersecting circles. The circles are burdensomeness, isolation, and fearlessness. Dr. Joiner would say, "When burdensomeness, fearlessness, and isolation are present, we have the capacity to complete suicide." I, as a professional, had a light bulb moment in how this applied to veterans. Veterans leave a close military community and try to acclimate to their past lives. They may struggle with addiction or PTSD and feel isolated in their current community. For fearlessness, they have seen things that I cannot even imagine, so death itself might not scare them. Veterans as a high-risk group make sense.

The GLBTQ+ community is also considered an at-risk group. Now, let me be clear. This is an at-risk group not because of their lifestyle, choices, beliefs, or identity but it is for how the community responds to them. There may be discrimination, harassment, and rejection. An example is a person who comes out to their family and is kicked out of their home. The fact that they are experiencing discrimination, homelessness, and rejection makes them an at-risk group, not because of their lifestyle or how they conduct themselves. Trevor Project came out with a research study that said that we could reduce young people's risks for suicide by 40% if they have just one well-meaning, positive adult in their life. It does not have to be a parent and could be a coach, mentor, teacher, or community member.

We have already named burden, isolation, and a capacity for suicide as a powerful combination. Last but not least would be technology use. Currently, we are still gathering a lot of data on technology and social media. What if I told you there was a certain number of hours of social media that subjects you to a higher risk for suicide? Some of you are hoping it is like six to 10 hours, but the magic number is three. Three or more hours of social media a day increases your risk for suicide. The researchers are saying part of it is where you fit it in. Let's apply this to teenagers once again. Teenagers, at this point, are overscheduled and do not have much extra time. Some work after school and have extracurricular activities, so their days are full. Many are not on social media until the wee hours of the morning, way past their bedtime. It may be 2 or 3 am, and they are sleep deprived. Now we have this vicious combination of not only comparing themselves to others through social media, but they are now sleep-deprived, anxious, and depressed. Teens are the most anxious and depressed we have ever seen, according to Dr. Jean Twenge's work. Three or more hours of social media a day increases our risk, not because of the social media itself, but what it does to us. It is worth thinking about as you work with clients to ask them about their technology use, specifically social media.

As we continue to engage, we also need to look at the other side of the coin. We have looked at risk and stressors, and now we must look at protective factors. What is keeping your client alive? If you are comfortable, you can outright say that. "Thank you so much for telling me what's going on. What's keeping you alive? What's keeping you here with me today?" 

• Suicide Protective Factors
  • External
  • Internal

(Flemons, D., & Gralnik, L., 2013)

We can break protective factors into external versus internal. External factors are things outside of them that are keeping them alive, like a job, a pet, a family member, a spouse, a child, religious beliefs, or a community. It might also be unfinished projects they want to complete before they die.

Internal examples would be things like spiritual beliefs. Religious or spiritual beliefs can be in both categories depending on the person. There could also be a fear of death and pain. Maybe they have a fear that if they make an attempt and survive it, their life will be worse than it is now. They may also not want to put their family through that. Sometimes, these are the deeper, darker conversations around protective factors. What we are doing impacts their emotions or state of mind. Internal could also be things like hope. Maybe they still have hope for something better. If they are a young 20-something, they may think, "I may get a great job," or, "If I find the love of my life, my life will change." Sometimes that shows up on the internal protective factors list.

With that being said, the one thing I can recommend to all of you is not to suggest protective factors to your clients. Learn from all of our mistakes. We cannot say that their family or a pet is a protective factor. This does not bode well for a client. They need to develop their protective factors as part of a safety plan. The idea here is quantity over quality. We want as many protective factors as possible. For example, a veteran on a crisis hotline days before I went into grad school said, "I'm suicidal, and I have a plan and a means, but I have one protective factor." His one protective factor was his dog. He was worried that if he died by suicide, no one would be there to take care of his dog. As you can imagine, if something happened to that dog, we would have problems keeping him safe—the more protective factors, the better. Helping the clients reflect on what is keeping them alive currently or even using memories of what would keep them alive is crucial.

Returning to Daphne, we are starting to talk about her stressors. She has some significant stressors around work, her relationship ending, and her parent's divorce. She also has anxiety and depression, so she started working with you. When asked about protective factors and she said, "I have two. I have my grandma and my cat." These are two things that are keeping her alive. We need to file this information away to work with our client around safety planning as that next step.

Respond: Level of Risk

• High Risk
• Moderate Risk
• Low Risk

(Erbacher, T., 2005)

Before we get to safety planning, we need to respond by identifying our clients' risk levels. The level of risk is problematic because the categories do not fit everyone. This is our best effort right now. These are subject to change because these three categories are not intuitive or helpful for all populations.

A high-risk person has suicidal thoughts, plans, means, and intent. All the boxes are checked, and they have many risk factors. They also may have minimal protective factors. There is immediacy, and we need to do something right now. An example is a client who says, "I'm going to die using that firearm that is loaded in the back of my car."

Additionally, if you have a client where everything feels like a risk or weapon for them to die by suicide, they are also high risk. This person may say, "I could take this pencil or paperclip and kill myself," or "I could jump off that overpass over there." This is also a high-risk individual because we cannot keep them safe if everything is a risk for their plan of suicide.

Moderate risk is the most challenging and tricky of all categories because anything can bump them up to high risk, like that veteran losing his dog. They may also bump down to low risk if they have a healthy relationship that keeps them present and with us. However, most of us will monitor their suicidal thoughts and provide resources. We may also schedule more sessions with them to have a clear view of what is happening and navigate their level of risk.

In contrast, the 10.3 million people who have had suicidal thoughts are automatically categorized as low risk. This is a problem with this rating system. It could have been decades ago that a person had a suicidal thought, but they are still low risk. I think these categories will change down the road, but for now, low risk is suicidal thoughts, even in the past. They need resources like a hotline, a text line, and plenty of protective factors.

• Acute vs. Chronic Risk
  • Acute
  • Chronic
  • Action Steps

(Freedenthal, S., 2018)

One thing to distinguish for this risk category is acute versus chronic. Acute is immediate. When we think about the medical model, acute is, "I have to respond immediately." This might be 911, an ambulance, someone coming to get them, hospitalization, M1 hold, 72-hour hold, or any of those things. Acute is immediate action taken by us.

Chronic, on the other hand, is a response to a population of people who are showing up saying, "I have had suicidal thoughts for many years. Currently, I am not at risk of myself or of others." How does this look? As comedian Frank King would say, "Suicide is always on the menu for someone who has chronic risk." An example is a flat tire. Your options are changing the tire, getting someone to help you change the tire, or you could die by suicide." This is the dark humor of Frank King. Many people with chronic suicidal thoughts say this is relatable because they are always there. If you are having a bad day, you could just die. However, there are no action steps. "I need to pursue this right now." For the chronic person, the action steps will look significantly different. We will not hospitalize someone with chronic suicidal thoughts because they are not at risk. We will monitor them and keep talking about it. But to this person, suicide is a comfort, almost like a last resort. Telling them to take it off the table or the menu is not worthwhile and not productive for a chronically suicidal person. Instead, we are going to look at their relationships and protective factors.

Action steps for acute and chronic are about relationship building, coping skills, etc. With Daphne, we know her risk factors, stressors, and protective factors. At this point, we are trying to figure out the risk level of what she has going on. As we talk more about suicide, she says, "I have a plan. I plan to jump off the overpass by my house." This is a significant plan because there are many overpasses where she lives. This puts her in a high-risk category because everything is a risk. A different client might say, "I plan to stop eating." This would be a different risk level as compared to Daphne. Hopefully, this is helping you to put all the puzzle pieces together. Next, we will see how to support Daphne with safety planning.

• Safety Planning
  • Baseline Wellness
  • Warning Signs and Triggers
  • Personal and Professional Supports
  • Make the Environment Safe
  • Action Plan

(Flemons, D., & Gralnik, L., 2013)

Daphne is at high risk because of the overpass plan. Let's say that she is coming back into care with you after a hospitalization, and she needs to have a safety plan in place. Frankly, safety plans are good for all sorts of things like domestic violence, addiction, substance use, and suicide. I think safety plans can be applicable in lots of different areas.

There are five components of a typical safety plan. The first is baseline wellness. What does it look like when they are well? Does the client have self-awareness? "When I am well, I am animated, take my medications, go to work on time, and am present in my relationships." You also want to see if they can identify specific, measurable things, like what it looks like when they are well versus unwell. Self-awareness can be powerful in starting the conversation of safety planning. It is not just about, "Let's keep you from killing yourself." It is asking how we know when you are functioning and well versus unwell.

From there, it transitions nicely into warning signs and triggers. Warning signs are internal things. What is happening inside that tells them they are not doing well? They may feel nervous, anxious, tearful, have a short fuse, and are angrier. They may be restless and not sleeping well.

In contrast, triggers are the things outside of them that are happening that could contribute to their risk for suicide but also contribute to safety needs. Triggers like relationship conflict, a significant other relapsing, or times of the year like holidays and trauma anniversaries. I cannot tell you how often clients have come in and said, "I do not feel good," or "I'm feeling down." I first ask, "Is there anything significant about today, this month, or this season that might be contributing to how you feel?" And nine times out of 10, the client says, "This was the season when I was sexually assaulted," "This is when my grandma died," or "This is when I got in a car accident." It may be the holidays, and the client has not seen their children in 10 years because they are estranged. Many triggers contribute to why someone is feeling unwell.

I want them to have that dialogue with us about what is on the inside and what is around them, not making them feel well. From there, we can talk about personal and professional support. Personal support for the youngest generation is critical because we often hear, "Nobody cares. I do not feel connected." We have to be careful how we frame this question. Personal support may be, "Who can you call or has distracted you in a healthy or lighthearted way?"

Although people are more willing to talk about their mental health, they are resistant to talking about suicide because they fear that someone will hospitalize them. Personal support might be more about healthy distraction than talking about suicidal thoughts. So I frame it as, "Who can distract you? Who sends you funny cat videos or memes that cheer you? Who can talk about themselves to get you out of your head?" When framed that way, all of a sudden, even that young person has somebody they have for their safety plan. Personal support does not have to be linked entirely to the suicidal component, but someone who can provide a healthy distraction can be helpful. Professional supports include you and me, the hotline, the text line, and other supports around suicide and mental health, like the ER. You can say, "These are your options when you are not feeling well mentally or suicidal."

What are the action steps that are going to support the person in making their environment safe? For example, are we making sure that the medications are secure, or do they have a partner or spouse that can monitor that those are not accessible? Do we need to remove firearms, sharp objects, or secure things that could be considered a weapon?

They may need to be supervised. After-school hours when there is no supervision, from 3 to 5 pm, are when most youths attempt suicide. Part of the safety plan may be that the client will hang out at a friend's house, go to grandma's, or stay in the after-school program. They need some structure to help them have a safe environment. For each client, that is going to be unique to them and customized to their experience. There is not a one-and-done plan for the environmental safety piece. It needs to be a collaborative element with your client. We want them to start talking about what they are willing to do or what they are resistant to doing so that it is feasible.

Last but not least, what are the action steps? What will they try first, second, and third to reduce their intensity of wanting to die by suicide? Is it calling a friend or using the hotline? Is it playing a sport or watching a show? What will help take some of that intensity or be a healthy distraction? Is the action plan going to go into a crisis stabilization unit? The plan may be that they will walk themselves into the ER, call support, and say, "I'm not okay. Help me."

The beauty of safety plans is that they can be changed and modified anytime. You may have a first draft with a client, and the next week, they say, "You know what, I tried those things, and they did not work." Updating or modifying the plan is always okay to ensure we try something else to meet the client's needs. Safety plans are all about empowering the client to have a choice other than dying by suicide via healthy coping skills.

Daphne's safety plan includes grandma and her cat because those are protective factors for her. We also identified that she enjoys being out in nature when she is not stressed out about work. Thus, part of her safety plan may include walking and being out in nature, calling grandma for a chat, and petting her cat. You want action steps customized to the client they are willing to try.

Anyone who is part of the safety plan or an action step should be informed. It would be best if you tried to get a release to talk to that person or encourage your client to tell them. In Daphne's case, grandma is not surprised to see her when she shows up. It is much easier for the client in a vulnerable place to do this if everyone is on the same page.

Tasks: Documentation

• Level of risk, including factors
• Steps taken by professional and/or family members
• Outcome

(Shea, S., 2011)

The last part of our acronym, of ALERT, is tasks. As I mentioned earlier, if you do not document it, it did not happen. We need to document the level of risk, including the factors, steps taken by other people or us, and hopefully an outcome. The steps taken by you or other people are crucial.

A formal suicide assessment and a note about your time with them should be in the file. If you have a family member coming to pick up the teenager to take them to the ER, we need to document that the family member verbally agreed to take them. You are not responsible for the family member not following through, which, unfortunately, does happen. They tell you one thing and do something else. It is crucial to document what they verbally agreed to do.

The outcome might be that they were evaluated in the ER and then sent home. You should update your documentation with this timestamp to show an outcome of what you did as a mental health professional assessing for suicide. In Daphe's case, they decided to hold her for a week to help her stabilize and adjust some medications for her depression and anxiety. The safety plan is in place for her release, with documented outcomes and conversations with the hospital staff.

That is a quick rundown of the ALERT acronym.

Summary

I have included the references I mentioned today in our presentation, which covers everything from that technology component we talked about to social media to tips and techniques for professionals asking someone about suicide. Check them out for further development of your professionalism around suicide. 

You can contact me, as I am always happy to be a resource for all of you. I hope you feel more confident about assessment and treatment using the ALERT acronym. This is the best practice response right now for suicide.

Frequently Asked Questions

One of the most common questions from our community is, "What if they do not have any warning signs?"

This is the type of client that scares us. We cannot help them or provide any helpful component to keep them alive if there are no warning signs. These clients are outliers, as most clients will have warning signs that we can see based on all the risk factors we discussed today. They are going to have different stressors even if they are hiding certain things from loved ones. Sometimes it is about putting puzzle pieces together.

The good news is if a client is talking about suicide, the hope is they want something to change. They are telling us that things are not good or that they feel hopeless. Hopefully, this is helping you feel reassured.

With the statistic that 25% of us that will have a client die by suicide, I want to ensure that there is a support network in place for all of us. There are many other trainings out there. It is essential to have these conversations about the impact. Cliniciansurvivor.org is a website for clinicians who have unfortunately had the experience of a client dying by suicide. The American Association of Suicidology, also known as suicidology.org, has lots of resources for clients, families, and us as clinicians.

References

Alter, Adam L. (2018). Irresistible: The rise of addictive technology and the business of keeping us hooked. Penguin Books.

Erbacher, T. A., Singer, J., & Poland, S. (2014). Suicide in schools: A practitioner's guide to multi-level prevention, assessment, intervention, and postvention (school-based practice in action) (1st ed.). Routledge.

Freedenthal, S. (2018). Helping the suicidal person: Tips and techniques for professionals. Routledge.

Flemons, D. G., & Gralnik, L. M. (2013). Relational suicide assessment: Risks, resources, and possibilities for safety. W.W. Norton & Company.

Joiner, T. E. (2005). Why people die by suicide. Harvard University Press. 

Shea, S. C. (2011). The practical art of suicide assessment: A guide for mental health professionals and substance abuse counselors. Mental Health Presses.

Twenge, J. M. (2017). IGEN Why today's super-connected kids are growing up less rebellious, more tolerant, less happy-and completely unprepared for adulthood and (what this means for the rest of us). Atria Books.