Reviewing Suicide Prevention Skills

By Jessica Crowe, MSW, LICSW

You have a new client. Or maybe, it is a current client with a history of suicidal ideation, attempts, and self-injurious behavior. You know what to do.

You can hear the words of your graduate school professor: “Pay attention to the words. Social workers need to hear the words their clients say out loud. What are they saying? Unsafe. Uncertain. Unstable. But, it is more than just listening to the words. Pay attention to the behavior. Social workers need to assess their clients’ behavior. What are they doing? Isolating. Impulsive. Irrational. Pay attention to the mood. Social workers need to evaluate their clients’ mood. How do they appear? Depressed. Dyspeptic. Defeated.”

You complete the risk assessment, as you should. Your client needs to be hospitalized. You’ve got this. You have done this so many times. Your client is assessed at the hospital and admitted. And after two days ... discharged. Now what?

A Few Statistics
According to the American Foundation for Suicide Prevention (AFSP), 42,773 Americans die by suicide each year; about 117 suicides occur each day. In addition, for each suicide, there are 25 more people in the United States who survive a suicide attempt.

Increasing awareness within the community is crucial in order to increase our population’s understanding and knowledge to help save a life. Suicide is the 10th leading cause of death in the United States and almost one-half of our population’s deaths by suicides are from firearms.

Non-Hispanic white males have the highest rate of death by suicide, followed by American Indians and Alaska Natives.

More than 30% of LGBTQ youth report attempting to end their life by suicide within the last year; more than 50% of youth who identify as transgender will have had at least one suicide attempt by the time they are 20 years old.

The AFSP also notes the following statistics:

Individuals 85 years or older have the highest rate of death by suicide.
Death by suicide is the second leading cause of death for individuals aged 15 to 24.
Hispanic females have the highest rate of suicide among adolescents.
Female adolescents have a higher rate of suicide attempts; however, male adolescents are four times more likely to die by suicide.

This field requires social workers to be aware of the warning signs and risk factors of suicide in order to have the ability to intervene, offer treatment, and prevent it. We need to work extensively on increasing our clients’ protective factors in order to decrease the risk factors.

Protective Factors
According to the Suicide Prevention Resource Center (SPRC) and Western Interstate Commission for Higher Education (WICHE), protective factors include the following:

effective mental health care;
connectedness to individuals, family, community, and social institutions;
problem-solving skills;
contacts with caregivers;
religious faith;
coping skills;
life satisfaction;
sense of responsibility to family;
reality testing ability; and
strong therapeutic relationship.

Cognitive behavioral therapy and dialectical behavioral therapy both have evidence to support treating individuals to prevent suicidal ideation, self-harm, and suicide attempts. Therapy should also be utilized to increase an individual’s protective factors as these factors decrease suicide risk.

Risk Factors
When working with clients who are struggling with severe mental health issues, it is crucial for social workers to have the skills to complete extensive risk assessments and comprehensive safety plans in order for individuals to receive proper care and prevent further harm. It is also important to understand the difference between warning signs and risk factors. According to the SPRC, warning signs are directly related to imminent risk; however, risk factors are not. Although risk factors can increase an individual’s risk of suicide, it does not necessarily mean that an individual is at imminent risk of suicide.

Warning Signs
According to WICHE and SPRC, the following signs are considered the strongest indications of suicide risk:

threatening to hurt or kill oneself, or talking of wanting to hurt or kill oneself;
looking for ways to kill oneself by seeking access to firearms, available pills, or other means; and
talking or writing about death, dying, or suicide, when these actions are out of the ordinary for the person.

Don’t Perform Evaluation Like a Checklist
It is good practice to ensure you are asking the questions that need to be reviewed when conducting a risk assessment, but we can keep our list to ourselves. It’s important that we don’t talk to our clients as though this is a checklist, because completing a risk assessment is more than a task to complete; it is an essential conversation to ensure we are doing everything that we can to help our client preserve his or her life. When a client is experiencing suicidal ideation or extreme hopelessness, we need to remember how difficult this situation may be for our client. We need to remember to utilize our core clinical skills: empathy, active listening, validation, and use of self.

When conducting risk assessments, if a client has a history of death by suicides within their family, we need to be sensitive to our client’s feelings. This would mean our client is a suicide-loss survivor. Our assessment should not include the question, “Has anyone in your family committed suicide?” We should ask if anyone in his or her family has died by suicide. It is also pivotal that we do not frame questions where the desirable answer implies, “No.” The words we choose to use and our tone of voice are important.

Screening tools can be utilized to assist with the evaluation process when a client may be experiencing or displaying risk factors and/or warning signs of suicide. The Substance Abuse and Mental Health Services Administration/Health Resources and Services Administration Center for Integrated Health Solutions has screening tools available at www.integration.samhsa.gov/clinical-practice/screening-tools#suicide.

What Should Be in Your Client’s Safety Plan?
First, it is important to determine whether it is safe for the client to be alone. If it is deemed unsafe for the client to be alone, an adult natural support should be identified to remain with the client 24/7 before, during, or after the crisis as needed. If it is not possible to identify an adult natural support and your client is not safe to be alone, you should contact 911 for your client to be evaluated at a hospital.

Per SPRC and WICHE, support personnel should be adept in the following:

identifying triggers;
developing coping skills to prevent triggers and to utilize when they arise;
removing access to lethal means or objects that are sharp/unsafe; and
offering provider contact information, including the National Suicide Prevention Lifeline (1-800-273-TALK [8255]) 911, or a local hospital emergency department.

Documenting Suicide Risk
According to Stacey Freedenthal, PhD, LCSW, when going back to the beginning with a client that has a history of suicidal ideation, attempts, and self-injurious behavior, it is crucial to document all of the components of your risk assessment and rationale behind your decision-making. Documentation of suicide risk should state more than, “Client denied suicidal ideation at this time.” It is also important to document the safety plan that you created with your client and/or in consultation with colleagues/supervisors, in addition to the typical information that you include in your client documentation form. Increased face-to-face and phone contact is recommended during times that your client is experiencing suicidal ideation in order to continue to assess whether your client needs additional care at a hospital. Following up with your client is crucial in the prevention process.

Are You Teaching Others the Risk Factors and Warning Signs?
As professionals, it is essential to help increase our community’s knowledge regarding suicide prevention. We can all work together to decrease deaths by suicide and to increase support among communities.

— Jessica Crowe, MSW, LICSW, is the coordinator of evidence-based programming and program evaluation at Tides Family Services in Cumberland, RI.