When dealing with a suicidal client, it is important to complete a risk assessment to determine the level of suicidal intent, plans and availability of means.
There are no definite criteria to help a clinician choose between inpatient and outpatient care of a suicidal patient, however, a patient with a plan, access to lethal means and a time-frame is considered to be at high risk and hospitalisation should be considered.
Many tools used by health professionals to assess suicide risk rely heavily upon verbal information from patients, despite the majority of interpersonal communication being of a non-verbal nature. To facilitate a more thorough risk assessment, both verbal and non-verbal cues must be assessed.
Some examples of non-verbal cues may include:
- Downcast eyes
- Less attention to appearance
- Psychomotor retardation of speech or movement
Verbal cues may include comments like:
- “Everyone would be better off without me.”
- “I don’t think I can take this much longer.”
Asking some probing questions may help you begin assessing the risk of suicide:
- “Other people with similar problems sometimes lose hope. Have you?”
- “With this much stress, have you thought about hurting yourself?”
- “Have you ever thought about killing yourself?”
A comprehensive suicide risk assessment should explore the following
Current suicidal thoughts
- Are suicidal thoughts present?
- When did these thoughts begin?
- How persistent are they?
- Can they control them?
- What has stopped the person acting on their thoughts so far?
Presence of a suicide plan
- Has the person made any plans?
- Is there a specific method and place?
- How often does the person think about the plan?
Important note: A suicide plan or preparation for death, such as saying goodbyes and putting affairs in order, indicates serious suicidal intent.
Access to means
- Does the person have access to means to carry out their plan? For example, is there a firearm available?
- How deadly is the method?
- Type of occupation? For example, police officer, farmer (access to guns), health worker (access to drugs).
Important Note: If a person has developed a potentially fatal or effective plan and has the means and knowledge to carry it out, the chances of dying from suicide are much higher.
History of suicidal behaviour
- Has the person felt like this before?
- Has the person harmed themselves before?
- What were the details and circumstances of the previous attempts?
- Are there similarities in the current circumstances?
Communicating with an emotionally distressed person can be difficult, but it is important to persist and gather the information required to estimate the risk, identify protective factors and determine the appropriate management.
The communication approach: some suggestions
- Establish rapport – adopt an open body language (maintain eye contact, lean forward and use a quiet voice).
- Use a calm, patient, non-judgemental, and empathic approach.
- Begin with supportive statements and open-ended inquiries. (“I hear how difficult things are for you at this time. Some of my patients with similar problems/symptoms have told me that they have thought about ending their life. I wonder if you have had similar thoughts?”)
Risk assessment questions
A hierarchy of screening questions that gently leads to asking about suicidal intent is an accepted method of risk assessment. Ask specific questions about self-harm, suicidal thoughts, plans, attitudes towards suicide, history of suicidal behaviour, thoughts of death, and feelings of hopelessness. These may include:
- “Are you feeling hopeless about the present or future?”
- “Have things been so bad lately that you have thoughts that you would rather not be here?”
- “Have you had thoughts about taking your life?”
- “When did you have these thoughts and do you have a plan to take your life?”
Protective factors for suicide
In addition to an assessment of the risk, a comprehensive approach to management of suicide focuses on the identification and fostering of protective factors, which reduce the risk of suicide. Protective factors to consider when creating a management plan include:
- Adaptive coping skills
- Effective problem-solving skills
- Sense of competence
- Supportive work environment
- Positive relationships with colleagues
- Professional development opportunities
- Access to employee assistance programs
- Relationship to family
- Sense of responsibility
- Involvement and opportunities to participate
- Affordable, accessible supportive services
Managing the risk of suicide
In consultation with the client, decide the next steps to be taken to maintain safety.
This could involve contacting the client’s supports, referral to an appropriate mental health service or developing a safety contract. For more information about support options for someone at risk, please refer to Assessing support for clients at risk.