Suicide Risk

According to the National Institute of Mental Health (NIMH; 2003), 29,350 people died as a result of suicide in 2000. It has also been estimated that 1 of every 60 Americans has experienced the loss of a loved one due to suicide, and it follows that many more personally know someone who committed suicide. Although there is no annual national data on the number of attempted suicides, it has been reported that there are an estimated 8-25 attempted suicides to 1 completion.

The evaluation and management of suicidal risk is a source of great stress for most mental health practitioners (Corey, Corey, and Callanan, 1993). Because the question is not “if”, rather “when” will a counselor deal with a suicidal client? awareness and training in suicide assessment and intervention is paramount.

As a counselor-in-training it is important to begin training in suicidology. This module is designed to begin to facilitate awareness of the information and processes of suicide assessment and intervention. Much of the information presented is applicable to a variety of populations. There is a great deal of information on suicide assessment and intervention as it relates to specific client populations. It is recommended that counselors engage in on-going training in issues related to working with clients who are suicidal.

If you are a counselor-in-training concerned about a client in your care, it is highly recommended that you seek consultation with a supervisor or instructor.

Ethical and Legal Issues of Suicide for Counselors

Nonmaleficence is the ethical principle addressing the counselor’s responsibility to “do no harm” including the removal of present harm and the prevention of future harm (Gladding, 2004). Of course, “harm” can be defined in a variety of ways.

Confidentiality

For counselors, confidentiality is a foundational ethical standard. Confidentiality is the ethical duty to fulfill the promise that client information received during therapy will not be disclosed without authorization. As such, it follows that breaching confidentiality can result in “harm” to the counseling relationship and subsequently the client. Confidentiality is addressed in Section B of the Ethical Standards of the American Counseling Association Section B.1.a speaks to respect for client privacy. “Confidentiality becomes a legal as well as an ethical concern if it is broken, whether intentionally or not” (Gladding, 2004).

Confidentiality Exceptions

Because confidentiality is such a critical issue within counseling, exceptions to confidentiality must also be heavily considered. What if not breaking confidentiality leads to “harm”? Section B.1.c. outlines the exceptions to confidentiality including the fact that confidentiality does not apply “when disclosure is required to prevent clear and imminent danger to the client….” This exemption was written with the suicidal client in mind, clarifying that counselors have a duty to protect client from harm and that this supersedes the harm that may happen due to a breach of confidentiality.

The complexities surrounding confidentiality are brought to the forefront when dealing with a suicidal – or potentially suicidal – client. Any decision to breach confidentiality should be made with careful consideration. The difficulty in making a decision, even in cases of suicide risk, lays in assessing “clear and imminent danger.”

“Determining that a client is at risk of committing suicide leads to actions that can be exceptionally disruptive to the client’s life. Just as counselors can be accused of malpractice for neglecting to take action to prevent harm when a client is determined to be suicidal, counselors also can be accused of wrongdoing if they overreact and precipitously take actions that violate a client’s privacy or freedom when there is no basis for doing so” (Remley & Herlihy, 2001).

Negligence

Negligence results from some type of wrongful action committed by one person, which results in “injury” to another person. As a general legal principle, a court must find the following four to be true:

1. A duty was owed by the counselor to the client

2. The duty owed was breached

3. There is sufficient legal causal connection between the breach of duty and the client’s injury

4. Some injury or damages were suffered by the client

With regard to the first issue, counselors have a duty to take steps to prevent client suicide. “Counselors have established themselves as mental health professionals, and the law imposes on counselors practicing in all settings the responsibility of knowing how to accurately determine a client’s risk for suicide” (Remley & Herlihy, 2001). It is not required that counselors always be correct in making their assessments of suicide risk, but they need to operate from an informed position and “fulfill their professional obligations to a client in a manner comparable to what other reasonable counselors operating in a similar situation would have done” (Remley & Herlihy, 2001).

The following are considered reasonable duty for counselors in terms of suicide prevention (Remley & Herlihy, 2001):

• Counselors must know how to make assessments of a client’s risk for suicide and must be able to defend their decisions

• When a decision is made that the client is a danger to self, counselors must take whatever steps are necessary to prevent the harm

• Actions to prevent harm must be the least intrusive to accomplish that result

Brems (2000) summarized the following questions related to negligence:

1. Was the counselor aware or should have been aware of the risk?

2. Was the counselor thorough in assessment of the client’s suicide risk?

3. Did the counselor make “reasonable and prudent efforts” to collect sufficient and necessary data to assess risk?

4. Were the assessment data misused, thus leading to a misdiagnosis where the same data would have resulted in appropriate diagnosis by another mental health professional?

5. Did the counselor mismanage the case, being either “unavailable or unresponsive to the client’s emergency situation?”

6. Was the counselor negligent in the way she or he designed her or his intervention with the client after assessing risk?

7. Did the counselor make adequate attempts to keep the client safe (i.e., set up a plan of contingencies with appropriate resources, phone numbers, etc)?

8. Did the counselor remove the means to be used by the client in the suicide attempt?

9. In cases of minors, were parents or caretakers informed of the client’s potential risk?

What can counselors do to protect themselves and subsequently their clients?

• Counselors should inform clients of the limitations of confidentiality through standard “informed consent” procedures.

  • A professional counseling standard is to inform clients about the procedures of counseling including statements of confidentiality, limits to confidentiality, the process of counseling, counselor theory and interventions, as well as the potential benefits and risks of counseling. Limits of confidentiality are specific around the issue of suicide or “harm to self.”

  • For instance: “All interactions between the counselor and client, including scheduling of or attendance of appointments, content of sessions, progress of sessions, or counseling records are confidential. There are some legal and ethical exceptions to confidentiality. If there is evidence of clear and imminent danger or harm to yourself and/or others, a counselor is legally required to report this information to the authorities responsible for ensuring your safety and the safety of others …”

  • There are a variety of ways to convey informed consent. Regardless of how it is done, the limits of confidentiality related to “harm to self” must be stated.

• Counselors should begin their study of suicide assessment prevention early and continue to stay current through professional development activities regarding suicide and crisis intervention and ethical/legal issues in counseling (Laux, 2002)

• Counselors should be familiar with suicide risk factors , procedures for suicide assessment, and guidelines for intervention (Brem, 2000)

• Counselors should abide by the standard of practice to consult with other mental health professionals to aid in assessing for suicide risk and interventions. It is important to look for consensus and follow the advice in making decisions (Remley & Herlihy, 2001)

• Counselors must properly document the process of suicide assessment and intervention through case notes and reports (Brem, 2000)
  As reported by Brems (2000), “as long as mental health and health professionals have been able to show prudent and responsible care (through assessment of risk and tailored intervention planning), the courts have tended to rule in favor of the practitioner” (p. 166).

Freemouw, Perczel, & Ellis (1990) note, “Any therapist, regardless of how competent, successful, and skilled, may lose a client through suicide. What will distinguish this therapist from another who was clearly negligent, careless, and indifferent to her or his client’s suicidal state is the presence of a well-documented, thorough client record” (P. 10).

Special Considerations for Minor Clients

The issue of confidentiality for minor clients is complex. While counselors are encouraged to maintain the confidentiality of minors in the same way as adults, legally, parent’s rights to information about their children override the counselor ethical obligation of confidentiality in most cases. This is due, in part, to the fact that minors are not seen as competent to give “informed consent” and therefore this power belongs to parents.

For counselors working with minor clients (including, but not limited to, school counselors), it is recommended that you become familiar with ethical and legal issues related to counseling children and adolescents.

With regard to suicide prevention and intervention, it is typically best practice to make parents/guardians aware of suicide risk for their children. Technically, the professional counselor’s legal liability ends when parents have been notified that their child is at risk for suicide and prevention actions have been recommended (Remley & Sparkman, 1993).

However, considerations as to whether this is in the ultimate best interest of the child remain fundamental (for instance, if the child sites his/her relationship with parents as a factor in the decision to attempt suicide). In addition, counselors have an obligation to follow up with a child, if parents or other significant others fail to act on prevention recommendations. In the vast majority of cases, it will be necessary to inform parents of the child’s risk for suicide. How effectively this is done takes forethought and intention. Proactively taking similar steps with minor clients that you would take with adults (informed consent, involving them in as much decision-making as possible, following up and supporting parents/guardians) are important steps in this process.

The Need to be Knowledgeable and Prepared

Regardless of where you work as a counselor, you are likely to provide services to someone who, at minimum, is expressing suicidal thoughts.

Statistics

The following are statistics related to suicide in the United States from the Center for Disease Control: National Center for Injury Prevention and Control:

• More people die from suicide than from homicide. In 2000, there were 1.7 times as many suicides as homicides

• Suicide took the lives of 29,350 Americans in 2000

• Overall, suicide is the 11th leading cause of death for all Americans (it has been as high as the 9th leading cause)

• Males are more than 4 times likely to die from suicide than are females. However, females are more likely to attempt suicide than are males

• In 1999, white males accounted for 72% of all suicides. Together, white males and white females accounted for over 90% of all suicides. However, during the period from 1979-1992, suicide rates for Native Americans (including American Indians and Alaska natives) were about 1.5 times the national rates. From 1980-1996, the rate of suicide increased 105% for African-American males aged 15-19.

• 57% of suicides in 2000 were committed with a firearm

• Suicide rates increase with age and are highest among Americans aged 65 years and older.

• Persons under age 25 accounted for 15% of all suicides in 2000. From 1952-1995, the incidence of suicide among adolescents and young adults nearly tripled.

• For young people 15-24 years old, suicide is the 3rd leading cause of death. In 1999, more teenagers and young adults died from suicide than from cancer, heart disease, AIDS, birth defects, stroke and chronic lung disease combined

Regarding suicide attempts the following are estimates:

• 775,000 suicide and 30,900 completions in the US each year (average over last 10 years)

• 5 million living Americans have attempted to kill themselves

• Most people who complete suicide have attempted 4 times

• There are an estimated 8-25 attempted suicides to one completion; the ratio is higher in women and youth and lower in men and elderly

Suicide Myths

In addition to the prevalence of suicide attempts and suicide deaths, another reason to undergo study and training in suicidology as a counselor is to be able to differentiate from fact and common myths regarding suicide. “In fact, the argument has been made that dispelling myths about suicide is the single most important step in the societal prevention of suicide.” (Brems, 2000, p. 162).

• Suicide is only committed by people with severe psychological problems

  • In truth, many people who successfully complete suicide had not received a prior psychiatric diagnosis. It would be common to be diagnosed with a mood disorder, such as depression, but a very small percentage meet the criteria for mental illness (Brems, 2000).

• Suicide usually occurs without warning

  • Most suicide attempts are preceded by a verbal threat or warning. It is reported that at least two-thirds of clients who attempt to kill themselves tell someone about their intent. In addition, most suicide victims (approximately 70%) have received medical/psychological care in the month prior to completion. Evidence shows that adolescents often tell their school peers of their thoughts and plans. They may also express their cry for help through non-verbal gestures.

• People who are suicidal will always be prone to suicide

  • Nobody is suicidal at all times. The risk for suicide varies across time, as circumstances change. Suicide can be induced by a temporary crisis, therefore once resolved, the person may never have suicidal ideation again.

• Discussing suicide may cause the client to want to carry out the act

  • Talking about suicide provides the important opportunity for communication. Quite contrary to common beliefs, talking about suicide may actually decrease a person’s risk for carrying it out. Considering that the threat may be a cry for help, discussion of suicide permits a means of validating the client’s feelings. The first step toward prevention often comes from talking about feelings. Of course, talking about suicide should be carefully managed.

• When a person has attempted suicide and pulls out of it, the danger is over

  • A suicide attempt is regarded as an indicator of further attempts. Indeed, the greatest period of danger may occur after a person has made an unsuccessful attempt.

• The tendency toward suicide is inherited

  • One potential indicator of suicide risk is a familial suicide, while this behavior may be modeled, there is little evidence that there is a genetic link to suicide. Other factors that may contribute to suicidal ideation and attempts (affective disorders) may be inherited.

• Nothing could have stopped someone once he/she decide to take his/her life

  • Suicides can be prevented. People can be helped. Suicidal crisis can be relatively short lived. In many cases, suicide threats and gestures are cries for help that, when addressed, can lead to improvement in mood and subsequent prevention of the act.

• A suicidal person who begins to show generosity and share personal possessions is showing signs of renewal and recovery

  • In many cases, if a suicidal person shows sudden elevation in mood and/or begins to give away possessions, this is a warning sign that the person has made a final decision to follow through with the intent to commit suicide.

• Suicide is always an impulsive act

  • While warning signs may be subtle, they are often present. Suicide is not always impulsive, rather, it is often carefully considered and intentionally planned.

• If a person talks about suicide, the individual won’t really try it

  • While there are instances of “attention-seeking” behavior, talking about suicide can be a plea for help and can be a late sign in the progression toward a suicide attempt. Those who are most at risk will likely show other signs in addition to talking about suicide.

10 Commonalities of Suicide

1. The common purpose of suicide is to seek a solution

2. The common goal of suicide is cessation of consciousness

3. The common stimulus in suicide is intolerable pain

4. The common stressor in suicide is frustrated psychological needs

5. The common emotion in suicide is hopelessness-helplessness

6. The common cognitive state in suicide is ambivalence

7. The common perceptual state in suicide is constriction

8. The common action in suicide is egression

9. The common interpersonal act in suicide is communication of intention

10. The common consistency in suicide is with lifelong coping patterns

Risk Factors and Warning Signs

What is possible, in working to prevent suicide attempts, is to recognize common crises and “warning signs” that may precipitate a suicide attempt. We then can make an effort to reach out to these people at risk.

Being aware of the risk factors and commonly associated variables of suicide is the first step in being able to assess for suicide risk and lethality on which interventions are subsequently based. There are a variety of risk factors associated with suicide, from immediate issues to long-term predictors. Keep in mind that there are also protective factors that also need to be considered in assessment.

Risk and lethality are related to the presence, intensity, and number of factors. While many of these factors may appear to be of a general nature, it is the clustering of these factors that contributes to the person’s mood, belief system, and coping ability that may lead to the risk of suicide. Additional risk factors for children are also presented.

Immediate Suicide Predictors

• Previous attempt or attempts: The method; The rescuer

• Verbal suicide threat

• Suicide Plan: Method; Availability of means; Decisions of time and place; Lethality of plan

Life Events or Conditions

• Presence of triggering or precipitating event: Client attributes ideation to an event or trigger; Timing of event? (During period of emotional distress?)

• Psychiatric History: Depression; Bipolar; Schizophrenia; Anxiety Disorders; Personality Disorders (more likely gestures/attempts); Discharged from psychiatric hospital (within 3 months); Adaptation to prior psychological treatment

• Substance Use: Drugs, Alcohol

• Physical Illness: Chronic, incurable, and painful conditions

• Loss of Relationships: Death of relative or close friend; Terminal illness of a relative or close friend; End of a relationship through divorce, separation, or estrangement; Anniversary date of loss

• Loss of status or security: Job; Money or savings; Status, self-confidence; Religious faith; A dream; Major life changes; Developmental; Trauma; Other environmental stressors

• Family variables: Family history of rejection or instability; Family history of suicide

Emotional or Behavioral Factors

• Suicide Ideation: Expressing thoughts of death, suicide, or wishes to be dead

• Fantasies about Suicide: Positive fantasies about death or aftermath

• Social Isolation: Few, if any, close relationships; Showing loss of interest in friends or pleasure in usual activities

• Hopelessness: Expressed feelings of hopelessness, despair, guilt, helplessness; Inability to articulate reasons for living

• Sudden mood change: Sudden, unanticipated signs of improvement in mood; Sudden disappearance of depressed or other symptoms; Suddenly becoming calm and resolved

• Perception of current emotional state and perceived choices: Belief that current emotional pain is intolerable and inescapable; Unable to think of alternate reasons, viewpoints or choices; Belief that suicide is only option to relieve pain

• “Personality” Variables: Hostility; Perfectionism or overly responsible behavior (leads to self-blame and guilt); Level of impulsivity; Pessimism; Dependency; Rigidity

• Change in appetite or weight: Suddenly eating less or losing weight

• Change in sleeping patterns: Sleeping less than usual, or very little

• Decrease in activity level and response rate: Speaking and/or moving with unusual speed or slowness; Decrease in sexual drive; Diminished ability to think or focus; Complaining of, or displaying reduced energy level

• “Preparation” actions: Giving personal, valued articles away; Writing a will; Planning for the care of those left behind

Demographic Variables

• Gender: Male (succeed more); Female (attempt more)

• Race: White; Native Americans (Native Alaskans); Other

• Age: Elderly; Teens and young adults

• Marital status: Separated, widowed, divorce

• Employment: Loss of job or change in status; Unemployed; “High risk” job setting

Warning signs for children (ages 5-12)

Three or more of these behaviors lasting for an extended period of time (e.g., 1 month) would signal a need for assessment:

• Sudden and dramatic changes in eating or sleeping patterns lasting for an extended period of time (e.g., over 1 month)

• Frequent (2-3 per week) night terrors causing child to have extreme anxiety, which persist for an extended period of time

• Sudden increase in bedwetting or bedsoiling, when this had not been a problem, and when it persists for an extended period of time

• Child’s sudden change in mood resulting in severe crying spells, extreme sadness, rageful outbursts, or complete withdrawal, that do not seem related to any external event (such as a death of a family member, or a pet), and which last for an extended period of time

• Artwork, pretend play, or peer play that depict consistent themes of death, violence, loss, and which persist for an extended period of time

Any one of these behaviors on their own would indicate a need for assessment:

• Child’s displaying extreme sexualized behavior, beyond what a child of that developmental stage would normally display or have knowledge about

• Child’s obssessional talk about death, mutilation, or violence (several times per day)

• Child’s acting out mutilating behaviors towards self, others, or animals.

Protective or Inhibitory Factors

In assessment, it is also important to look for protective or inhibitory factors as well as warning signs. Protective factors are those that when activated or discussed, may actually inhibit the client from raking action to commit suicide.

Social Support Factors

• Significant Others: Number; Family; Close friends; Neighbors; Coworkers

• External Social Supports: Professionals with crisis management or therapeutic skills

• Willingness of clients to use supports

• Level of Social Acceptance experienced

Protective Factors

• Problem-solving skills: Has history of ability to solve problems and create solutions; Has demonstrated skills for handling emotional crises

• Future Plans: Expression of concrete and detailed future plans

• Family Commitments: Raising children; Care for Siblings

• Religious or Spiritual beliefs

• Cultural Factors: African American; Cultural beliefs against suicide

• Willingness to sign a No-Harm Contract

Of course, there are exceptions to these factors that may make them risk factors. For instance, in some cultures suicide may be endorsed as a means of protest or redemption. In addition, although the commitment to care for and see children grow may be an inhibitory factor, it may become a risk factor if the client perceives the children would be better off without the client.

Counselors also need to be alert to client denial and the lack of complete truthfulness in discussing these factors. Brems (2000) suggests that while protective factors need to be explored carefully, they should also be approached with some skepticism.

Procedures for Assessment of Suicide Risk

***Counselors-in-training are highly encouraged to seek consultation with supervisors or instructors if there is immediate concern regarding a client.

Although there is much information to gather, there are no shortcuts to suicide assessment. Risk assessment requires directness, intentional questioning, and careful listening. The essential skills and conditions of counseling (empathy, reflections, restatements, attending, active listening, etc.) are important in suicide assessments and intervention. Information that is gathered during assessment should be documented.

Knowing when a suicide assessment is necessary

There are recommendations that counselors conduct suicide risk assessments on all clients presenting for therapy (Laux, 2002). It is common practice that suicide ideation is assessed through intake forms and intake interviews

Specifically, clients presenting with depression or depressive symptoms or in states of crisis should be questioned for suicidal ideation. If using depression inventories, special attention should be given to questions related to suicidal thoughts (such as question 9 on the Beck Depression Inventory).

As the client tells his/her story, the counselor should be listening (and looking) for the presence of risk factors and protective factors. As the number of risk factors increases particularly in the absence of protective factors, suicide risk increases and should be questioned.

As a counselor attends to the client, language that reflects feelings of hopelessness and despair should be noticed and explored. For instance, it is paramount to ask for elaboration on statements such as “I can’t go on anymore.” “I want to end it all.” “I wish I were dead.” “This is hopeless, I don’t see any way out of this situation.”

In truth the first intervention for suicide is the assessment, in other words assessment begins the process of suicide intervention.

The point is to assess for risk AND leverage (information that can be used to intervene).

Questions to Guide Suicide Assessments

Either as part of an intake assessment, or based on information you have gathered indicating that a suicide assessment is in order, the starting point is:

• Ask directly if the client has thoughts of suicide. “Have you thought of committing suicide?”

• “Are you thinking of killing yourself?” In this case, subtlety is counterproductive.

If the answer is anything but a confident “No”, then assessment should proceed.
Even in cases when a client answers by saying “No”, continued exploration and discussion of what the client has said or presented that may be related to suicidal ideation is warranted.

• Have there been previous attempts? (When, surrounding circumstances, rescuer?)

For example: “When?” “How often?” “What happened?” “What was going on in your life at the time?” If attempts were made, then exploration of method and rescuer should be explored. If the client indicates having thoughts or having made attempts in the past, even if there is no current ideation, past experiences should be thoroughly explored. If the client does not answer questions about suicide, the answers are vague, or if the client conveys that he/she has entertained thoughts of suicide then…

• Are the thoughts pervasive or intermittent? When was the last time the thought occurred to the client? Do these thoughts typically occur in times of crisis?

• Is there a specific precipitating event?

Even if answers to these questions continue to be vague or seem to be more intermittent, ideas of how the person might commit suicide need to be explored.

•   Is there a plan? What are the details of the plan? How extensive is the plan?

Examples: “How have you thought of killing yourself?” “When would you carry out the plan?” “Do you have a date and time?” “Where would you be?” “Who would you want to find you?”

• What is the lethality of the means/method?

• Is there access to the identified means?

Examples: “If you were to commit suicide, how would you do it?” “Do you have the pills?” “Where are they?” “What type of pills would you take?” “What type of gun?” “Where would you get the gun?” “Do you have bullets?” “Where is the gun? The bullets?” “Do you have a rope/cord?” The previous questions have related specifically to suicide ideation. In addition, questions that assess for risk and protective factors are explored. All of this information aids in determining risk and subsequent interventions.

• Is the client using drugs or alcohol?

• What are the client’s social supports?

• Does the client have a religious or spiritual affiliation?

• How is the client discussing suicide and potential aftermath? Do fantasies seem to be positive or painful?

• Is the client able to see any alternatives to suicide?

• How does the client respond to challenges to distorted thinking?

The Use of Assessment Instruments

Various instruments have also been used assessing for suicide risk. These include assessments such as the Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) and the Beck Depression Inventory (Beck & Steer, 1987) and the BDI-II (Beck, Steer, & Brown, 1996) that were not specifically designed to measure suicide ideation, but what is measured correlates with suicide ideation and can therefore be helpful.
In addition, there have been instruments developed specifically to assess for suicide ideation. These instruments include:

• Beck Scale for Suicide Ideation (BSSI) (Beck, Kovacs, & Weissman, 1979)

• Suicidal Ideation Scale (SIS) (Rudd, 1989)

• Suicide Behaviors Questionnaire (SBQ) (Cole, 1988)

• Reasons for Living Inventory (Linehan, Goodstein, Nielsen, & Chiles, 1983)

• Suicidal Ideation Questionnaire (Reynolds, 1987)

Some of the above instruments have also been validated for use with adolescent or college populations. In addition, there are instruments that have been specifically developed for these populations.

• College Student Reason for Living Inventory (Westefeld, Cardin, & Deaton, 1992)

• Suicidal Ideation Questionnaire – junior high version

• Multiattitude Suicide Tendency Scale – for adolescents (Orbach, Milstein, Har-Even, Apter, Tiano, & Elizure, 1991)

• Fairy Tales Test (Life and Death Attitude Scale for the Suicidal Tendencies Test (for children 10 and younger) (Orbach, Feshbach, Carlson, Glaubman, & Gross, 1983)

The use of suicide assessment instruments can be helpful, but should not replace the assessment interview. There are also times (due to the emotional and cognitive state of the client) when administration of a test would not be prudent.

*For a discussion on suicide assessment instruments, see Brems, 2000 and Westefeld, Range, Rogers, Maples, Bromley, and Alcorn, 2000).

Determination of Risk and Intervention

This section focuses on level of risk as determined by the presence and combination of risk and protective factors and subsequent intervention information. In determining risk and interventions, it is important to consult knowledgeable colleagues.
***Counselors-in-training are highly encouraged to seek consultation with supervisors or instructors if there is immediate concern regarding a client.

Assessment and Determination of Risk

Although there is much information to gather, there are no shortcuts to suicide assessment. Knowledge of risk factors and protective factors is essential in assessment of suicide risk. None of the warning signs (risk factors), if found in isolation, should cause you to be concerned, however the combination of several signs should prompt you to take several steps.

Part of decision-making involves evaluating whether protective factors outweigh risk factors or vice versa (Brems, 2000). As part of this evaluation it is also imperative that the counselor consider whether this balance is stable or if it may change in the future. For instance, if a mother has a strong protective factor related to being there to raise her daughter, but the daughter is 17 and about to graduate from high school and leave for college, the balance may then shift.

Risk may be judged by considering the following factors (Brems, 2000):

1. the degree of psychological disturbance

2. suicidal intent by self-report and objective evaluation

3. the particular suicidal behavior exhibited

4. ethality of plan/method selected

In addition, the following issues could also be considered (Brems, 2000):

1. imminence of the behavior (from likely never to occur immediately)

2. clarity of danger (from vague or no time, place, method, and opportunity)

3. intent (from no wish to die to strong wish to die)

4. lethality of behavior (from non-lethal method to highly lethal method)

The assessment of risk is not based on a strict formula.

In general, LOW risk would indicate the presence of ideation or passing thoughts without a plan and means, etc. MODERATE risk would indicate a serious consideration of harm, ideas of a plan and means, no access, the existence of some support, some risk factors present. HIGH risk would indicate the details in the plan, the greater degree of lethality and strength of intent combined with presence of risk factors and absence of support.

Immediate Predictors

 Life Events or Conditions

 Psychiatric History

Emotional or Behavioral Factors

 Social Supports