The most telling assessment question involves simply asking someone directly and specifically if they have ever thought about killing themselves. Obviously, this topic is difficult to talk about- it’s heavy, dark, and uncomfortable but asking these types of questions is the first step in effective suicide prevention and intervention. “Have you ever thought about killing yourself? Have you ever thought about committing suicide? Have you ever thought about hurting yourself? Do you ever wish you were dead? Do you ever have thoughts about ending your life? How do you feel about living? How do you feel about dying? If you think about suicide, do you have a particular mental picture of what suicide might look like?”
Assess suicidal ideation: frequency and content of thoughts- “When did you begin having suicidal thoughts? Did any event (stressor) precipitate the suicidal thoughts? What are those thoughts like? If someone were listening to your suicidal thoughts, what might they hear? How often do you have thoughts of suicide? How long do they last? How strong or intense are these thoughts? Did you feel suicidal this morning? Yesterday? Last week? Last month? When were these thoughts the worst? What do you do when you have suicidal thoughts? What did you do when they were the strongest ever? Have you told anyone about your thoughts of suicide? How did they respond? Have you created a suicide note or letter in writing or online? If yes, who saw it? How did they respond? What would it accomplish if you were to end your life?”
Ask about any history of previous attempts by the person, any family members, or their peers– “Have you ever tried to kill yourself before? Have you rehearsed how you might do it? What happened? How did other people respond? Has anyone in your family committed suicide? Has anyone in your family attempted to commit suicide? Have any of your friends tried to kill themselves? Have any of your friends died due to suicide? How did other people respond? How did it make you feel after hearing about it? How do you feel about it now?”
Assess their intent, means, and plan- Their intent is the extent to which the person expects to carry out the plan and believes the plan or act to be lethal.“Do you have any thoughts about how you would kill yourself? What are the ways you would end your life? If you were to kill yourself, how would you do it? Where would you do it? When would you do it? Do you have a day in mind of when you would do it? Do you have a timeline in mind for ending your life? Is there something (an event) that would trigger the plan? Do you have the (gun, drugs, rope, etc.) you would you use? Where is it? What have you done to begin to carry out the plan? How likely do you think you are to carry out your plan? How close do you feel like you are to killing yourself? What would happen that would get you closer to ending your life? How confident are you that this plan would actually end your life? Have you made any other preparations or arrangements?
Explore precipitants and triggers– “What makes you feel more suicidal? What people, experiences, or feelings make you feel suicidal? What might happen that would bring you closer to killing yourself? What makes you feel worse?”
Review the person’s mental health history– Assess for current and past history of mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD (any history of trauma or abuse), personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity)- co-morbidity and recent onset of illness increase risk. Explore any symptoms of anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, or command hallucinations. Ask about any changes in treatment- discharge from psychiatric hospital, provider or treatment change.
Assess for indirect words or behaviors– Ask the teen and their family members about any of the following words or behaviors. Giving away any prized possessions, withdrawing and isolating from others (e.g., desire to be left alone), acquiring lethal instruments (e.g., razors, scissors, firearms, knives, pills, etc.), talking about “leaving” or “going away”, phrases like “I’d be better off dead” “If I see you again…” “I wish I hadn’t been born…” “Everyone would be better off without me”, writing poems, songs, or stories about death, making out a will, making arrangements for family members, exploring and talking about what death would be like, social media posts (Facebook, Instagram, Twitter, etc.) about the above. A sudden sense of calm and happiness after being extremely depressed can mean that the person has made a decision to commit suicide.
Safety proofing– Remove any firearms, weapons, knives, blades, razors, scissors, ropes, pills, etc. from your home. Ask the person if they are willing to discard any lethal instruments or means- if not, explore their reasons for keeping the items and the advantages and disadvantages of keeping and discarding the items with the person.
Problem-solve other ways to stop pain– Often people who are thinking about suicide, just want the pain to end. They view the one option of escaping this pain as suicide. Helping someone problem solve other ways to reduce pain and strong negative emotions is an important part of the assessment and intervention process.“What makes you feel better? What might make you feel better?”
Create a safety and self-care plan– Use the MY3 app, the client will fill out their warning signs, coping strategies, distractions, support network, strategies to stay safe, and reasons to live. Have the person e-mail their MY3 safety plan to their parents, caregivers, and providers (e.g., therapists, psychiatrists, teachers, pediatricians, etc.). Also, create a client self-care plan- a list of things they can do to take care of themselves (e.g., coping strategies, religious/spiritual practices & beliefs, etc.). Include phone numbers and websites for local and national crisis lines, chat lines, hospitals, and emergency rooms in safety and self-care plans. Here are some chat lines- http://us.reachout.com, https://www.imalive.org, http://www.crisischat.org Here are some phone lines- Youth helpline Your Life Your Voice at 1-800-448-3000, run by Boys Town National Hotline (for everyone); National Suicide Prevention Lifeline at 1-800-273-TALK (8255)
Explore their desire to live and reasons for living– “What stops you from killing yourself? What do you care about? What are your reasons for living? What or who do you care for/are responsible for? What makes you feel better? What makes you smile? What makes you laugh?”
Help the person build a life worth living– This might look like seeing a psychiatrist, joining a support group, volunteering, switching schools, changing jobs… “Imagine there was a miracle and you woke up tomorrow and your life was exactly how you wanted it. What would that look like?” Explore small actions the person can do to make steps in that direction.
Trust your gut and intuition– If a person cannot promise they will stay safe (i.e., not hurt themselves) between a current moment time and a future moment in time (e.g., between that day and the next scheduled session), try to move the appointment date to an earlier time. If the person still cannot promise they will stay safe or if you feel any hesitation about a person’s safety, call a mobile crisis team to conduct an additional suicide assessment (there is usually one in every county), take the person to the nearest emergency room, call 911, or move forward with a 5150. YOU ARE NOT OVER-REACTING.
Get your own supervision, consultation, and support– practice self-care, talk to family members and friends, speak with your supervisor, check out online forums, or join a parent support group.
Check out the resources out there– To Write Love On Her Arms, The Trevor Project, National Suicide Prevention Lifeline, Yellow Ribbon, The Jason Foundation, The Jed Foundation