Risk assessments are critical in determining the level of suicidal intent, plans and availability of means of a suicidal client.
While there aren’t definite criteria to help a clinician choose between inpatient and outpatient care of a suicidal patient, the presence of a plan, access to lethal means and a time-frame, generally indicates that the patient is at high risk. In these cases, hospitalisation should be considered.
Many of the methods used in the assessment of suicide risk tend to rely on patients providing information verbally. Despite this, the majority of interpersonal communication, including that between patient and client, tends to be of a non-verbal nature.
Comprehensive risk assessments will include the evaluation of both verbal and non-verbal communication.
Risk Assessments: Examples of verbal cues
- ‘There’s no point things aren’t going to get better.’
- ‘They’d be better off without me around.’
- ‘Can’t take this anymore.’
Risk Assessments: Examples of non-verbal cues
- Slowed speech/movement
- Less attention to appearance
- Downcast eyes
You can begin to assess the risk of suicide by asking direct questions like:
- ‘It sounds like you have a lot to deal with. Have you ever thought about hurting yourself?’
- ‘Sometimes people with a lot of problems and stress lose hope, have you?’
A thorough suicide risk assessment should explore the following
- Does the client have suicidal thoughts?
- When did these begin?
- How persistent are they?
- Is the client able to control the thoughts?
- What is stopping the client from acting on the thoughts?
Presence of a suicide plan
- Does the client have a plan?
- Have they specified a method or place?
- How often is the client thinking about their plan?
Note: Plans or preparations for suicide (like putting affairs in order, saying goodbyes) indicate serious suicidal intent.
Access to means
- Does the client have access to the means (e.g. weapons, medication) to carry out their plan?
- How lethal is the method?
- Does the client have an occupation that may mean they have access to lethal means (e.g., police officer, health worker).
Previous suicidal behaviour
- Has the client had suicidal feelings before?
- Do they have a history of self-harm?
- What were the details/circumstances of previous attempts?
- Are there similarities in the current situation?
It can be challenging to communicate with a client who is in distress, but it is important to be persistent. Gathering the above information will allow you to estimate the risk of suicide and decide on a management plan.
Suggestions for communicating with suicidal clients
- Build client-practitioner rapport (e.g. by using open body language, maintaining eye contact)
- Aim to be calm and patient. Use empathy and avoid judgement.
- Use supportive statements and ask open-ended questions (e.g.’It sounds like you are having a really difficult time at the moment. Some of my patients who have been through similar things have told me they’d thought about ending their life. I wonder if you’ve ever had similar thoughts?’)
Risk assessment questions
One accepted method of risk assessment is to work through a hierarchy of screening questions that gently lead to directly asking about suicidal thoughts, feelings, plans or behaviour. These may include:
- ‘Are you feeling hopeless about the present or future?’
- ‘Have you ever thought that you’d rather not be here?’
- ‘Have you ever thought about hurting yourself?’
- ‘Have you made any plans to take your life?’
Protective factors for suicide
A comprehensive assessment and management plan for suicide risk should also consider the recognition and promotion of protective factors to reduce the client’s risk of suicide. These may 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
Suicide risk management
The next step is to decide, in consultation with the client, on how to manage the risk of suicide and maintain safety. This may include referrals to other health professionals or services, contacting the client’s family or support network, or the development of a safety contract.
For more information about the support options for clients at risk of suicide, please refer to our Assessing support for clients at risk page.