Discuss River of Suicide

Discuss the importance of the River of Suicide. Why is it significant in assessing suicide risk?
Discuss the P.A.S.E.S. and the factors that increase risk. What impact do these have on risk assessment and what sorts of things should you pay attention to?

4.1 Introduction
Now that you have learned how to establish a connection and some rapport, this module will now take you into Step Two of the RAP Model: Assess the Individual. This step comes after you have had some interaction with an individual and you start to get the sense that they may be depressed and/or suicidal. Pay attention to that sense. That’s your gut telling you something. So now that you suspect they are suicidal, you will now learn how to assess their level of suicide risk.

Learning Outcomes

Once you have completed this module, you will be able to
1. identify the P.A.S.E.S. – signs and symptoms of a suicidal person
2. identify the most important factor in determining a person’s choice not to attempt suicide
3. assess an individual utilizing the Standardized Risk Assessment
4. plot the individual on the River of Suicide to further understand their level of risk
5. recognize the impact of being a member of a high risk population has on suicide risk
4.2 Key Terms/Concepts

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• P.A.S.E.S

• 8-Tier Risk Assessment

• Standardized Risk Assessment

• Lethality (L)

• Availability (A)

• Specificity (S)

• The River of Suicide

4.3 Step Two: Assess the Individual ( P.A.S.E.S.)

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P.A.S.E.S. in an acronym we use to help remember some of the most important clues, signs and symptoms that a person may be suicidal. A good way to remember this further is to assign a letter to each finger on one of your hands.
Web Resources
For more information on depression and its signs and symptoms, check out:

http://www.nimh.nih.gov/health/publications/depression/symptoms.shtml

4.3a Clues, Signs, and Symptoms Common to Suicide (P.A.S.E.S.)

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The following is a list of common signs that you may observe in a depressed or suicidal person. Also, watch for changes in what is normal for the person in crisis (so either an increase or decrease in a particular behaviour).
PHYSICAL
• Crying
• Sighing
• Flat affect/inconsistent affect
• Changes in appearance
• Sleeping patterns (too much or not enough sleep)
• Tired
• Appetite, weight, hygiene
• Aches and pains
• Avoiding eye contact
• Low voice (tone, rate and volume)
• A change in what’s normal for them
• Pay attention to symptoms consistent with reactive depression – what do depressed people’s bodies look and feel like?

ACTIONS
• Has a suicide plan
• Withdrawing/isolating
• Giving away possessions
• Reckless, risk taking behaviour
o Increased use of alcohol/drugs
o Promiscuity particularly in teenaged girls
o Risk taking behaviour with apathy (placing yourself in dangerous situations that could result in injury or death and not caring)
• “Wills & Bills†– preparing (paying bills, writing notes, making meals etc) or not preparing (running up the Visa, not paying the bills, not caring about anything).
• Actively seeking the means by which they may choose to kill themselves (stock-piling medication, preparing a noose etc.)
• Loss of interest in normally enjoyable activities

SELF-TALK
• Predominately negative self talk. Imagine what the person may be saying to themselves about themselves, even if it is not overt. What would you say to yourself if you were in their shoes? For example:
o “I’m a loserâ€
o “You’ll be sorry when I’m goneâ€
o “I’m a lousy father”
o “I’m a failure as a ____________”
o “Nobody would miss me anywayâ€
o “They’ll be better off without meâ€

EMOTIONS
• Remember the three most predominant emotions of suicidal people (as outlined in Module 2): Hopeless, Helpless & Worthless. Remember as well that most people are not going to just say they are feeling hopeless, helpless and worthless, but may express sadness, despair, anger, fear, anxiety, vulnerability, frustration and so on. It is from these expressions that you can then get a sense of how hopeless, helpless and worthless they are feeling.

SITUATIONS
• Remember the two main themes as outlined in Module 3 (Why Suicide?):
o Loss
o Change beyond a person’s control
4.4 Risk Factors/Protective Factors

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There are a number of factors to consider when assessing a person at risk’s potential to end their own life. Some of these factors increase risk while others are protective in nature (thereby decreasing risk). Following are 8 key factors. Click on the link to complete the activity.
Key Points of Activity
• Resources are the most important factor in determining an at-risk person’s potential to attempt suicide.
• It makes sense: the more support you have (emotional, social, familial, financial, etc.) that someone has, the less likely they are to attempt.

4.5 Standardized Risk Assessment

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So as you are talking with a person, you start to notice that they expressing a lot sadness and despair leading you to belief that they are feeling hopeless, helpless and worthless. You may also be noticing other clues, signs and symptoms as outlined in the P.A.S.E.S. So given all of this, what should you do you now?

That’s right, ask them!

Ask them what exactly? You need to be clear and direct when asking a person about suicide. Whenever you feel that there is the potential for risk, you need to do a risk assessment.

The following represents a written version of a suicide risk assessment. Please note that this is not intended to be something you read out loud while the person is present. This is a guide to support you in remembering a standardized risk assessment.

Your first question should be…Are you thinking of killing yourself?

This question is clear, direct and is based on the person’s thoughts. It has only two answers. In fact, closed ended questions form the basis of a risk assessment. Intervening with a potentially suicidal person is a two-handed approach. On the one hand, your rapport building skills and the focus on feelings as discussed in Module Three, represent half of the equation. It must be there in order for your intervention to be effective.

On the other hand, the risk assessment supports you in dealing directly with the urgency of the situation. Here the focus becomes gaining a clear picture of the level of risk. The questions as outlined in the Standardized Risk Assessment are designed to give you an accurate foundational view of the person’s level of risk.

It’s important to recognize that you need both the rapport and the urgency portions to intervene effectively.

The Standardized Risk Assessment is as follows:
ARE YOU THINKING OF KILLING YOURSELF?
YES NO
By answering “Yes†to this question, this person is at LOW RISK. If no, continue with building rapport and exploring resources.
Move on to ask the next question.
HAVE YOU THOUGHT OF HOW YOU WOULD DO THAT?
YES NO
By answering “Yes†to this question, this person is at MID RISK.
(i.e., Yes, I guess I would just hang myself) If no, continue with building rapport and exploring resources.
Move on to ask the next question.
LETHALITY

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DO YOU HAVE THE…(gun, pills, rope…)?
YES NO
By answering “Yes†to this question, this person is at HIGH RISK. If no, continue with building rapport and exploring resources.
AVAILABILITY

HAVE YOU THOUGHT OF WHEN…?
YES NO
If yes, use safety plan, contact additional resources. DO NOT leave alone. Defuse lethality/reduce access to the means when safe to do so. If no, continue with building rapport and exploring resources.
SPECIFICITY

*If the person has initiated or will initiate the suicidal act, this is ACUTE RISK and should be treated as a medical emergency*

**Follow your policies and procedures**
4.5a Suicide Risk Assessment: Lethality, Availability & Specificity (L.A.S.)

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The initial Standardized Risk Assessment consists of determining three things:

Lethality: How lethal is the means the person has chosen? (Pills vs. Hanging)

Availability: How available are the means? (Do they have them already? Can they get access to them easily?)

Specificity: When does the person plan to attempt? (Include details such as why then as opposed to any other time? Is it about opportunity or is there a significant anniversary or other important date?). Where do they plan to attempt? (Will they have access to intervention resources?)

Again, to clarify, remember:
Low Risk
• This person has Thoughts & Impulses (ideation) of suicide and has suicidal feelings (hopeless, helpless & worthless)

• Answers “yes†to the question “Are you thinking of killing yourself?â€

Mid Risk
• This person has Thoughts & Impulses + a Plan

• Answers “yes†to the question “Have you thought of how…?â€

High Risk
• This person has Thoughts & Impulses, a Plan + the Means

• Generally, the attempt should occur within 24-48 hours to be considered high risk but this is not always the case

• Answers “yes†to the question “Do you have the…?â€
Important Considerations for Assessing Suicide Risk Using the Standardized Risk Assessment
• If you start a risk assessment, always finish it, in order, as written. People at Low, Mid and High risk ALL have Thoughts and Impulses of Suicide – if you do not complete the Assessment, you will not know their level of risk.
• As a general rule, “Go until you hear Noâ€
• Make sure to ask the questions clearly and directly (much as they are written). Do not sugar coat or ask vague questions. This communicates to the person in crisis that you are uncomfortable talking about suicide. For example, “You’re not thinking about harming yourself, are you?†or “You’re not thinking of doing something stupid, are you?†Pay attention to your tone of voice. Watch you body language.
• Be aware of what your policies and procedures are within your workplace specific to suicide and follow them.

4.6 The River of Suicide

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Now that you have learned how to take someone through the Standardized Risk Assessment, you have a fairly good idea about what level of risk the person may be at. This however, is not a complete risk assessment. This section will take you through the final piece that allows you to further clarify and more accurately assess a person’s level of risk for suicide.

The River of Suicide allows you to “plot†a person on the River based on your initial assessment of their level of risk. For example, a person who you have assessed as Low Risk because they have answered “Yes†to “Are you thinking of Killing Yourself?†but “No†to “Have you thought of you how you would do that?†would be plotted at LOW on the River to begin with.

However, the River explores additional factors that elevate risk. For example, being a member of a high-risk population (as outlined in Module 1).

When you consider other factors that elevate risk along with your initial assessment of the person, your assessment in terms of the urgency of your response may increase.

Factors that Increase Risk
• Being a member of a high risk population (Inmates, People with Addictions, Mental Illness (In particular: Depression, Bi-Polar, Schizophrenia), Aboriginal youth, older white men, young men in general (16-24) gay/lesbian/transgendered youth)
• Knowing someone who has killed themselves
• Having past attempts
• Having no identifiable resources
• Recent Loss or Change
• Recent Abuse
• Postpartum Depression
1. To accurately assess a person’s suicide risk, first plot them on the River of Suicide based on your assessment using the Standardized Risk Assessment.

2. Then consider the factors that increase risk and move the person “up†on the River.

3. This will impact your overall assessment of their level of risk and as well the urgency of your response.

For example, you have assessed a person at LOW risk for suicide. You then learn they have three past attempts, the most recent of which was six months ago. They are also a member of two high-risk populations with being a young man and being an Inmate. As such, you would move this person up on the River to reflect their true level of risk (likely in this case HIGH).

Do you remember back in Module 1 where you learned that if you someone personally or professionally that has killed themselves, then this increases your risk of suicide? This is where this comes into play. But, it only counts when you are in an emotional crisis.

Remember as well, that it is not always a one for one. One factor does not necessarily mean you automatically move a person up one level. One factor may be enough to move up two levels, for example, if a person has no other factors but has 12 previous attempts with the most recent one being two weeks ago.

The factors will be weighed differently depending on the nature of each one. Past attempts always count. However, one past attempt 20 years ago will not be weighted as heavily as one that occurred six months ago.

The goal of suicide prevention is try to try and create “breaks†in the River – that is to work to prevent a person in crisis to moving up to the next level of risk.
4.6a The River of Suicide Practice Exercise

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Complete the River of Suicide activity, plotting each person (as outlined in the scenario) onto the River based on your assessment of their risk, combining their risk as indicated from the Standardized Risk Assessment, with the factors that increase the risk.
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Scenarios

1. Initially assessed at LOW risk with the Standardized Risk Assessment (has thoughts and impulses but no plan). Is a recovering alcoholic and has two past attempts within the last five years.

Correct Response

HIGH RISK – This person has two factors that elevate their risk: 1) being an alcoholic (High Risk Population) and, 2) having past attempts, and in particular because there is more than one.
2. Initially assessed at MID risk with the Standardized Risk Assessment (has thoughts of suicide and a plan but no means). Is a 21-year-old Aboriginal male.

Correct Response

HIGH RISK – This person has two factors that increase their risk: 1) being young and male (High Risk Population) and 2) being Aboriginal and young (High Risk Population).
3. Initially assessed as NO RISK (answered “No†to “Are you thinking of killing yourself?†). Is in an emotional crisis, has three past attempts (the most recent one 6 months ago), recently divorced, is a recovering addict and has recently been incarcerated.

Correct Response

HIGH RISK – This person is an example of why the Standardized Risk Assessment on its own is not enough. This person has responded “No†to “Are you thinking of killing yourself?†right now and yet they are considered HIGH RISK because of multitude of factors that are present here that increase their risk. These factors make it so that even though they are not thinking about killing themselves at the moment, in the midst of an emotional crisis, they could very quickly move to suicidal ideation. The factors that increase risk here are: 1) three past attempts, with one being very recent, 2) recently divorced (recent loss or change), 3) a recovering addict (High Risk Population), and 4) has recently been incarcerated (High Risk Population).
4. Initially assessed at LOW risk with the Standardized Risk Assessment (has thoughts of suicide but no plan). Is a 70-year-old Caucasian man who recently lost his wife.

Correct Response

HIGH RISK – This person has two factors that elevate their risk: 1) recent loss of his wife, and 2) being an elderly white male (High Risk Population).
5. Initially assessed at LOW risk with the Standardized Risk Assessment (has thoughts of suicide but no plan). Has one past attempt one year ago.

Correct Response

MID RISK – This person has one factor that increases their risk with one past attempt recently.

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