This article contains my review and outline of the podcast: SUICIDE ASSESSMENT: SHARPEN YOUR CLINICAL SKILLS by Jason McGlothlin
In the past, I’ve worked as a crisis counselor of a 24-hour crisis hotline where we received calls from persons throughout the state of Florida who were contemplating suicide. As with most social service agencies who work with clients who are suicidal, there was a protocol we used to assess suicidality in our callers and get them the help that they needed. The way in which they answered our questions determined the necessary steps we would take in responding appropriately to the caller’s needs. We would generally ask the client a set of 10-15 questions to gauge the immediacy of the client’s needs. Typically we asked questions like, “Do you have a plan” and scaling questions like, “On a scale from 1-10, how likely are you to carry out your plan?” Depending on how the client would answer and the quality of their answers, we would either refer them to outside resources (i.e. inpatient and outpatient clinics) that could help.
More recently, I took an internship at a social service agency in Brooklyn who serves clients in the community living with dual diagnoses. Most of the work done within the agency is case management where we assess the client’s needs for social service and connect them with help they need. Because the focus is on home health care, and many of the clients within the program have a serious medical condition, many of the assessment questions pertain to housing placements, medication management, nutrition, exercise, and physical health related content. There is less of a concern for the client’s mental and emotional well-being, so suicidality isn’t a focal point of screening.
In comparing the SIMPLE STEPS Model created by Dr. Jason McGlothlin to previous methods I’ve used in the past, I would have to say that his model is the best model to use. It’s thorough, simple, and easy to use. It gives the clinician a better sense of the client’s mental and emotional picture, lessoning the chances that a client presenting with suicidal ideation could slip through the cracks. I agree wholeheartedly with his approach and adverse opinion towards triage assessment of suicidality. Suicide is a serious issue. As professionally trained clinicians who wear the badge of integrity and boast that we care for our patients, it is our duty to be sensitive to client’s concerns and demonstrate a keen understanding and application of efficient and thorough research driven techniques and practice when working with clients who are mentally ill.
Of all the steps outlined in this model, I am very impressed by the Perturbation step. Assessing how much pain a client is enduring is very important to measuring how likely he or she is able to cope and safely manage their stress. Usually, pain is tied to an isolated event; so in this step, it allows the clinician to explore with the client past experiences that may have been very painful for the client to endure. Perhaps the client has never had the chance to talk these painful experiences out with someone before and this is his or her first chance to get it off their chest. During this stage in the suicide assessment process, it is important that the clinician is very sensitive and attentive to the client’s emotions. Pain is one of the few emotions that takes time to heal from. So demonstrating a caring and supportive attitude and expressing empathy towards the client is paramount.
- Face-to-Face – at what point of treatment are you looking at this client?
- Triage vs thorough way to do it.
- Triage Approach – 4 ways to look at suicide – PIMP (not recommended, unless rudimentary intake). One time thing, then need to have a more thorough, detailed approach to assessing suicide
- Plan, Intent, Means, Prior Intent
- Plan, Intent, Means, Prior Intent
- Preventative malpractice issue is the motivation behind using the preferred SIMPLE STEPS Model, which is a thorough, detailed way of assessing the client.
- SIMPLE STEPS Model*
- Based off all of the suicide assessment literature
- American Association of Suicidality – IS PATH WARM
- S – Are you Suicidal? When working with really young children, you may have to pose the question differently (i.e. Do you want to kill yourself? Have you ever thought about dying?) Avoid going into conversations about hurting yourself. If they say yes, go to the next question.
- I – Ideation. What’s the thought process of the suicidal client? Gives you a time frame of which the person is thinking about killing themselves. Lowest level = I’m not suicidal, I don’t want to die, I want to live. Next step, I want to die, but I don’t want to kill myself. After that, then you start getting into suicide ideation = I want to die, I want to kill myself….and I know how to do it. Ask the client the time frame of suicide. On a scale from 1-10, 10 being very likely, 1 being not likely at all, how likely are you to kill yourself within the next 72 hours?
- M – Method or the means in which they are going to kill themselves. Avoid assessing the lethality of the means unless you are trained properly to do it. Not our job to assess the means or assume that the client’s “passive” means aren’t going to kill them. Primary job – GET CLIENT HELP. Ask if the client has the means available. Do you have access to it now?
- P – Perturbation – Degree of emotional pain someone is in. How much pain are you in? How much pain does it take for you to kill yourself? You said you were an “8” what is it going to take for you to get from an “8” to a “10,” 10 = suicide.
- L – Loss. Experienced vs Perceived Loss. Example: I think my friend is going to move out of town (perceived) vs My friend is moving out of town (experienced). Assess the quality of each loss on a scale from 1-10.
- E – Earlier Attempts. The more attempts a client has had before, the more likely they will attempt suicide. What prevented you from killing yourself before? What intervened? Example: My dog came to sit on my lap and I know that if I killed myself there would be no one here to take care of my dog. Assess protective factors. What things keep you alive?
- S – Substance Use. One of the biggest contributing factors. Drinking? Any drugs? What happens as a result of the client’s drug use? Taking prescription medication? Medication compliance? How often do meds change?
- T – Troubleshooting. .What’s the client’s problem solving ability? Are you willing to stay alive? What happens before you think about committing suicide?
- E – Emotion and Diagnosis. 5 key emotional factors to working with clients with suicide. Hopelessness, Helplessness, Worthiness, Loneliness, and Depression
- P – Parents/family history. Is there a family history of suicide? Family history of mental illness. (maternal history focused). The more the client saw the depression in his mother, the more likely he is to become depressed and commit suicide.
- S – Stress and Life Events. How much stress and the way in which client deals with the stress. Quantity and quality of stressors. How many? Measure of intensity.
- Based off all of the suicide assessment literature
In the past, I’ve worked as a crisis counselor of a 24-hour crisis hotline where we received calls from persons throughout the state of Florida who were contemplating suicide. As with most social service agencies who work with clients who are suicidal, there was a protocol we used to assess suicidality in our callers and get them the help that they needed. The way in which they answered our questions determined the necessary steps we would take in responding appropriately to the caller’s needs. We would generally ask the client a set of 10-15 questions to gauge the immediacy of the client’s needs. Typically we asked questions like, “Do you have a plan” and scaling questions like, “On a scale from 1-10, how likely are you to carry out your plan?” Depending on how the client would answer and the quality of their answers, we would either refer them to outside resources (i.e. inpatient and outpatient clinics) that could help.
More recently, I took an internship at a social service agency in Brooklyn who serves clients in the community living with dual diagnoses. Most of the work done within the agency is case management where we assess the client’s needs for social service and connect them with help they need. Because the focus is on home health care, and many of the clients within the program have a serious medical condition, many of the assessment questions pertain to housing placements, medication management, nutrition, exercise, and physical health related content. There is less of a concern for the client’s mental and emotional well-being, so suicidality isn’t a focal point of screening.
In comparing the SIMPLE STEPS Model created by Dr. Jason McGlothlin to previous methods I’ve used in the past, I would have to say that his model is the best model to use. It’s thorough, simple, and easy to use. It gives the clinician a better sense of the client’s mental and emotional picture, lessoning the chances that a client presenting with suicidal ideation could slip through the cracks. I agree wholeheartedly with his approach and adverse opinion towards triage assessment of suicidality. Suicide is a serious issue. As professionally trained clinicians who wear the badge of integrity and boast that we care for our patients, it is our duty to be sensitive to client’s concerns and demonstrate a keen understanding and application of efficient and thorough research driven techniques and practice when working with clients who are mentally ill.
Of all the steps outlined in this model, I am very impressed by the Perturbation step. Assessing how much pain a client is enduring is very important to measuring how likely he or she is able to cope and safely manage their stress. Usually, pain is tied to an isolated event; so in this step, it allows the clinician to explore with the client past experiences that may have been very painful for the client to endure. Perhaps the client has never had the chance to talk these painful experiences out with someone before and this is his or her first chance to get it off their chest. During this stage in the suicide assessment process, it is important that the clinician is very sensitive and attentive to the client’s emotions. Pain is one of the few emotions that takes time to heal from. So demonstrating a caring and supportive attitude and expressing empathy towards the client is paramount.
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