Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline

Suicide and Life-Threatening Behavior 37(3) June 2007 353  2007 The American Association of Suicidology

Thomas Joiner, PhD, John Kalafat, PhD, John Draper, PhD, Heather Stokes, LCSW, Marshall Knudson, PhD, Alan L. Berman, PhD, and Richard McKeon, PhD

The National Suicide Prevention Lifeline was launched in January 2005. Lifeline, supported by a federal grant from the Substance Abuse and Mental Health Services Administration, consists of a network of more than 120 crisis centers located in communities across the country that are committed to suicide prevention. Lifeline’s Certification and Training Subcommittee conducted an extensive review of research and field practices that yielded the Lifeline’s Suicide Risk Assessment Standards. The authors of the current paper provide the back- ground on the need for these standards; describe the process that produced them; summarize the research and rationale supporting the standards; review how these standard assessment principles and their subcomponents can be weighted in relation to one another so as to effectively guide crisis hotline workers in their everyday assessments of callers to Lifeline; and discuss the implementation process that will be provided by Lifeline.

On January 1, 2005, the National Suicide anytime from anywhere in the nation and are Prevention Lifeline (1-800-273-TALK) was routed to the nearest networked crisis center. launched. Lifeline, supported by a federal Callers are then connected with a trained grant from the Substance Abuse and Mental telephone worker who can provide emotional Health Services Administration (SAMHSA), support, assessment, crisis intervention, and/ consists of a network of more than 120 crisis or linkages to local treatment and support re- centers located in communities across the sources, including emergency services. country that are committed to suicide pre- Two major goals of Lifeline are to pro- vention. Persons in emotional distress or in mote efficient access to this service so it will suicidal crisis can call the toll-free number at reach more people nationwide at risk of sui-

Thomas Joiner is Distinguished Research Professor and the Bright-Burton Professor of Psychol- ogy at Florida State University; John Kalafat is Professor, Rutgers Graduate School of Applied and Professional Psychology; John Draper is the Director of the National Suicide Prevention Lifeline program and Heather Stokes is the Director of Certification & Training of the National Suicide Preven- tion Lifeline program at Link2Health Solutions, Inc., New York City, operated through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA); Marshall Knudson is Director, Alachua County Crisis Center, Gainesville, FL; Alan Berman is Executive Director, American Association of Suicidology; and Richard McKeon, Center for Mental Health Services, SAMHSA. This project is supported by a grant to Link2Health Solutions, Inc., from SAMHSA. Address correspondence to Thomas Joiner, FSU Psychology, Tallahassee, FL 32306-1270; E-mail: [email protected] 354 NSPL Risk Assessment cide, and to ensure high quality of services to risk assessments. Kalafat, Gould, Munfakh, its callers so as to more effectively prevent and Kleinman (this issue) studied 1,085 sui- suicide. Lifeline established a subcommittee cidal and 1,617 nonsuicidal crisis callers to of American and Canadian suicide preven- eight crisis hotlines. The hotlines had agreed tion experts in March 2005 to consult on de- to use standardized, evidence-based suicide veloping standards and recommended prac- risk assessments and measures of crisis states, tices for its network of crisis centers. Lifeline’s assessed near the start and at the end of their Certification and Training Subcommittee’s calls; and, for those who consented, at a fol- (CTS) extensive review of research and field low-up call approximately 3 weeks after the practices yielded recommendations that are original call. Significant reductions in crisis embodied in Lifeline’s Suicide Risk Assess- and suicide status occurred during the calls ment Standards, which were phased in for and continued to the follow-up. Notably, in implementation beginning in January 2007, response to an open-ended question at fol- with the expectation of network-wide adher- low-up as to what was helpful about the call, ence by September 2007. 11.6% (n = 44) of suicidal callers said that the In this article, we provide the back- call prevented them from killing or harming ground on the need for these standards; de- themselves. scribe the process that produced them; sum- Follow-up assessments were conducted marize the research and rationale supporting with 801 of the 1,617 callers who had been the standards; review how these standard as- categorized by centers as nonsuicidal crisis sessment principles and their subcomponents callers. At follow-up, 52 (6.5%) reported hav- can be weighted in relation to one another so ing suicidal thoughts when they had origi- as to effectively guide crisis hotline workers nally called the centers, and 27 of these said in their everyday assessments of callers to they had told the crisis worker of these Lifeline; and discuss the implementation pro- thoughts. Crisis centers had not conducted cess that will be provided by Lifeline. risk assessments for these callers, and these callers were more distressed than callers who did not report suicidal thoughts. This study THE NEED FOR EVIDENCE- highlighted the need to inquire about suicide BASED RISK ASSESSMENT on crisis calls, particularly with more dis- STANDARDS tressed callers (see Gould, Kalafat, Munfakh, & Kleinman, this issue; Kalafat et al., this Because of their accessibility, crisis issue). hotlines are in a unique position to intervene In another study Mishara and col- with individuals at various points along the leagues (this issue) silently monitored 1,431 pathway to suicidal behavior, including the calls to 14 centers. Overall, when emotional moments or hours prior to fateful decisions. or cognitive changes occurred from the be- This special contribution to suicide preven- ginning to the end of the calls, such changes tion is undermined if staff members are un- were positive. Their report concluded that able, unwilling, or reluctant to persistently the centers had helped a significant number inquire about and explore suicidal thoughts of callers and may have saved some lives. For and feelings with callers. example, at the end of the calls, 52.3% of Recently completed SAMHSA-spon- callers were less confused and more decided sored evaluations of crisis hotlines’ processes about next steps, 48.7% were less helpless and outcomes employed monitoring of hot- and more resourceful, and 40% were more lines and follow-up of callers to hotlines. hopeful. These studies provided overall evidence in Of the 1,431 callers, 723 were not support of crisis hotlines’ role in responding asked about suicidality. Of the 474 who were to crisis and suicidal callers, while raising asked or who reported suicidal thoughts, no some concerns about the quality of suicide questions about the means were asked on Joiner et al. 355

46% of the calls. In 159 instances when the that persistent assessment of suicidal thoughts, helper was aware that the caller was consider- feelings, and plans, as well as of alternatives ing suicide and had determined what means and inhibitors, is the most effective way to to use, the helper asked only 30 of those call- reduce callers’ isolation, anxiety, and despair, ers if an attempt was in progress. Questions and to begin the exploration of alternative about prior attempts were asked of only 104 ways of addressing their problems. callers. The study characterized these risk assessments as not following the accreditation guidelines of the American Association of THE PROCESS OF DEVELOPING Suicidology or procedures mandated by their SUICIDE RISK ASSESSMENT own center directors. STANDARDS FOR It should be noted that failure to con- NETWORK CENTERS duct appropriate suicide risk assessments or to pursue clients’ suicidal communications is Establishing Expert Consensus not unique to crisis hotline staff, as this has on Standards been found also among professional mental health providers (Bongar, Maris, Berman, & In order to meet the goals of reaching Litman, 1998; Coombs et al., 1992) and more people nationwide at risk of suicide and among primary care physicians (Williams et serving them more effectively, Lifeline has al., 1999). Nevertheless, this finding for orga- engaged national and international experts nizations, many of which include suicide in- and stakeholders in suicide prevention who tervention as a primary part of their mission, provide ongoing consultation and advisement prompted the CTS of the Lifeline Network to the project. The CTS is comprised of ex- to make the development of standards for ev- perts in the field of suicide prevention re- idence-based risk assessment a first priority. search, training, crisis center evaluation, and Primarily due to their accessibility to administration. In order to better ensure the callers in immediate suicidal crisis, crisis hot- application of crisis center research findings lines must engage in the assessment of immi- into field practices, the CTS has strong rep- nent risk. As telephone services, crisis hot- resentation of crisis center directors as well. lines face unique challenges in conducting In addition to the research findings suicide risk assessments and intervening with from the Mishara et al. (this issue) and Kala- suicidal persons. Crisis workers must estab- fat et al. (this issue) studies indicating a need lish and maintain rapport with callers with for more consistent, thorough assessment of whom there is less control than in face-to- caller risk by telephone crisis workers, the face situations, who may be using a phone absence of evidenced-based suicide risk as- service primarily because they wish to retain sessment standards for crisis centers further this control, and/or may be reluctant to com- underscores the need to address this issue mit to face-to-face contact or ongoing treat- immediately. Based on this, the CTS identi- ment. They may also be using a phone ser- fied two goals relating to Lifeline’s suicide vice because they are currently in an acute risk assessment standards initiative: (1) iden- state of distress or suicidality. tify the most salient evidence-based risk and The challenge, then, is to conduct a protective factors that can inform our efforts systematic and thorough risk assessment to assess suicide risk during a telephone con- within the connection and flow of a tele- tact; and (2) work collaboratively with centers phone contact. To accomplish this, crisis staff to develop and deliver a pilot training pro- must be thoroughly familiar with the current gram on conducting risk assessments that can risk and protective factors for suicide, and be be adapted to and incorporated into crisis comfortable enough with the topic to weave centers’ current training programs. the risk assessment into the course of the call. Initially, the CTS determined that the Most importantly, crisis staff must be assured nature of crisis call center work required the 356 NSPL Risk Assessment ability to assess immediate (as opposed to center directors where the standards were long-term) risk factors. The group then ex- presented and discussed. Many of the direc- amined the results of a factor analysis con- tors reinforced the standards by stating that ducted by Gould et al. (this issue) on the sui- their current suicide risk assessment closely cide risk assessment instrument used in the reflected the core principles and subcompo- Kalafat et al. study (this issue), and compared nents. The one principle that seemed to be that with a similar analysis by Lifeline of a omitted in many suicide assessments was sui- research-based suicide risk assessment used cidal intent; however, consensus was reached by LifeNet, a Lifeline crisis center in New regarding the importance and necessity of York City. Other sample suicide assessments having suicidal intent assessed among crisis currently being used by networked crisis cen- and suicidal callers. ters were reviewed by the CTS to survey common field practices. The findings from Empirical Basis for the Standards these analyses were then cross-checked with several studies isolating significant, acute fac- Empirical research and clinical experi- tors in suicide risk assessment not specific to ence suggest that suicidality is a multifaceted crisis center work. The results of both the phenomenon. Research to date indicates that factor analyses and reviews supported the three facets—suicidal desire, suicidal capabil- designated four core principles for Lifeline’s ity, and suicidal intent—cover the domain of standards for suicide assessment: suicidal de- the phenomenon (and importantly, are not sire; suicidal intent; suicidal capability; and redundant with one another; Beck, Brown, & buffers/social connectedness. Steer, 1979; Joiner, Rudd, & Rajab, 1997; Joiner et al., 2003). We believe a fourth Crisis Center Input facet—buffers against suicidality—also needs to be included to provide a full framework Representation from network crisis for suicide assessment in the context of crisis center leadership was present at every level center hotline work. These four facets, as of the standards development and review. well as their subcomponents, were influenced Network crisis center directors were repre- by and are compatible with the “IS PATH sented on the CTS where the standards were WARM?” warning signs mnemonic (where I = developed and the Steering Committee ideation, S = substance abuse, P = purpose- where the standards were reviewed and ap- lessness, A = anxiety, T = trapped, H = hope- proved. less, W = withdrawal, A = anger, R = reck- After extensive revisions based on CTS lessness, and M = mood changes; Rudd et al., member discussions and Steering Committee 2006). In what follows, the four facets are de- and Executive Leadership Team feedback, scribed, some research on each is summa- the CTS introduced the suicide risk assess- rized, and the inter-relations of the facets are ment standards to over 40 crisis center direc- discussed (the four core principles and their tors across the country at the American Asso- subcomponents are summarized in Figure 1). ciation of Suicidology (AAS) Conference in May 2006. This allowed interactive input Suicidal Desire from the crisis center directors and supervi- sors present; members of Lifeline’s Con- In studies by Beck, Joiner, Rudd, and sumer Recipient Subcommittee also provided colleagues (e.g., Beck et al., 1997; Joiner et essential feedback that enhanced emphasis on al., 1997, 2003), suicidal desire has been assessment of protective factors (“reasons for shown to be comprised of the following com- living”), part of the fourth core principle of ponents: no reasons for living; wish to die; the standards. wish not to carry on; passive attempt (e.g., Lifeline then hosted a conference call not caring if death occurred); and desire for in June 2006 with Lifeline network crisis suicide attempt. Influenced by several other Joiner et al. 357

Figure 1. National Suicide Prevention Lifeline Suicide Risk Assessment Standards strands of research (e.g., Rudd et al., 2006; shame, or on the other hand, death by sui- Joiner, 2005, on burdensomeness; Williams, cide. The mental calculation in the mind of Duggan, Crane, & Fennell, 2006, on feeling the suicidal person, according to this per- trapped), the CTS has emphasized psycho- spective, is “my death will be worth more to logical conditions that, while not the same as loved ones than will my life.” suicidal desire, are strong contributors to Regarding feeling trapped, several it—namely, feeling trapped, feeling like there prominent models of the development of sui- is no alternative course of action or escape, cidal behavior emphasize that suicidal people feeling intolerably alone, intense psychologi- wish to escape psychological pain (e.g., cal pain, hopelessness, helplessness, and per- Shneidman, 1996), and that their state of ex- ceiving oneself as a burden on others. Of treme distress diminishes their ability to these factors, two in particular (perceived think of adaptive ways to do so. The combi- burdensomeness and feeling trapped) may be nation of desperately wishing to change their unfamiliar in risk assessment contexts. situation yet being unable to think of ways to Joiner’s (2005) theory of suicidal be- do so leads some people to consider suicide havior asserts that perceived burdensomeness as an escape. A roughly synonymous concept is a key component of the life-and-death psy- to feeling trapped is cognitive constriction; that chological processes of people seriously is, emotional crises tend to constrict people’s contemplating suicide. Suicidal people per- ability to solve problems, leading to a sense ceive themselves to be ineffective or incom- of desperation and feeling trapped, and sui- petent; moreover, they also perceive that cidal behavior becomes the option for escape. their ineffectiveness affects not just them, but A key point about suicidal desire is spills over to negatively affect others. Fur- that, although it is of clinical import, it is not, thermore, they perceive that this ineffective- by itself, very telling about suicide risk status. ness that negatively affects everyone is stable This is because suicidal desire is a common and permanent, forcing a choice between on presentation in those calling crisis hotlines in the one hand, continued perceptions of bur- distress, is a common symptom of mood dis- dening others and escalating feelings of orders ( Joiner et al., 1997), and indeed is a 358 NSPL Risk Assessment relatively common experience in the general tended to underscore that severe suicidal be- population (Kessler, Berglund, Borges, Nock, havior is fear-inducing and often painful— & Wang, 2005). Regarding suicide risk sta- high tolerance for fear and pain is thus tus, suicidal desire is roughly as indicative of relevant. risk as are high distress in a hotline caller, or The CTS, influenced by past work as the other prominent symptoms of depres- (e.g., Joiner, 2005; Rudd et al., 2006), has sion like anhedonia (inability to experience identified the following factors as at least pleasure in previously enjoyed activities) and contributory to and in some cases definitive sad mood. These symptoms and crisis-related of suicidal capability: distress are of concern (and should prompt rapid referrals for timely treatment), but • History of suicide attempt, particularly their endorsement alone is not enough to multiple attempts (Rudd, Joiner, & raise serious worry about imminent suicide Rajab, 1996). This factor is a clear risk. Rather, it is when suicidal desire occurs risk for future suicidality because, in in combination with other facets of suicidal- part, past behavior is a strong predic- ity—described next—that concern escalates. tor of future behavior. Relatedly, re- The presence of suicidal desire should alert search indicates that for those who one to explore and elicit information regard- resort to suicidality (especially re- ing suicidal capability and suicidal intent. peatedly) in the face of distress, suicidality may have become a primary Suicidal Capability way of coping, to the exclusion of more adaptive coping methods. The same series of studies that eluci- • History of/current violence to others dated the nature of suicidal desire has charac- (Conner, Duberstein, Conwell, & terized the components of suicidal capability. Caire, 2003). This factor’s relevance They are: a sense of fearlessness to make an resides in the fact that those who are attempt; a sense of competence to make an capable of violence or injury in gen- attempt; availability of means to and oppor- eral are capable of self-injury in par- tunity for attempt; specificity of plan for at- ticular. Moreover, this factor has spe- tempt; and preparations for attempt. cial relevance to those at risk for It is important to note that the suicidal homicide–suicide. capability factor, as defined above, relates to • Exposure to/impacted by someone else’s imminent plans and fearlessness about suicid- death by suicide. Some research has ality. Fearlessness about suicidality is a key suggested that the impact of suicide but underrecognized concept. Serious sui- on those left behind is associated cidal behavior is by definition fearsome and is with future suicidal behavior and in- often painful; many studies and clinical case creased frequency of mental health studies show that it is this fearsomeness that issues (Agerbo, 2003). prevents many people from acting on suicidal • Availability of means. Seeking access ideas. Those that do act have come to terms to means of suicide is a clear warning with the prospects of fear, and often pain. sign; past research has shown that it This point does not relate (at least not as di- is part of a cluster of symptoms re- rectly) to fearlessness in general, as there are flecting dangerous parameters like many people who are fearless but who, as a capability and intent ( Joiner et al., function of their fearlessness, are not neces- 1997, 2003; Rudd et al., 2006). sarily at risk for death by suicide (e.g., fighter • Current intoxication (Bartels et al., pilots, NASCAR drivers). Relatedly, this 2002). Current intoxication (e.g., point is not intended to romanticize suicidal with alcohol, cocaine, or LSD) di- behavior as brave or tough; rather, it is in- minishes problem-solving abilities Joiner et al. 359

and reduces inhibitions, thus con- clarity in thinking, and is a key symp- tributing to elevated risk for suicidal tom of mood disorders. Research has behavior. documented insomnia as a key risk • Tendency toward frequent intoxication factor for suicidality. (Bartels et al., 2002). This tendency makes intoxication in the near future Research results indicate that suicidal more likely, with attendant risks of desire and suicidal capability factors are not decreased problem-solving abilities similarly related to key suicide-related indi- and lowered inhibitions as noted ces. For instance, Joiner et al. (1997, 2003) above. showed that, although the presence of either • Acute symptoms of mental illness (Cava- factor is of clinical concern, the suicidal capa- nagh, Owens, & Johnstone, 2002). bility factor is, relatively speaking, of more The onset or recurrence of severe concern than the suicidal desire factor. The and acute symptoms of the vast ma- suicidal capability factor was more closely re- jority of mental disorders contributes lated than the suicidal desire to pernicious to many risk factors noted herein; for suicide indicators such as having recently at- example, psychological pain, agita- tempted suicide as well as eventual death by tion, insomnia, being out of touch suicide. with reality, etc. • Recent dramatic mood change (Cava- Suicidal Intent nagh et al., 2002). A dramatic mood change can be indicative of the onset Some researchers have viewed suicidal or worsening of a mood disorder or intent as part of suicidal desire or suicidal ca- other disorders—disorders which in pability, but the CTS has separated it out, for turn heighten the risk for suicidal be- two key reasons. First, even more than desire havior. and capability, its relation to suicidality is • Out of touch with reality (Cavanagh et plain—those who intend a behavior often en- al., 2002). Problem-solving ability act it. In the previously noted study by Kala- and inhibitions are both lowered by fat et al. (this issue), in the weeks following psychosis; command hallucinations the suicidal callers’ original calls to crisis (e.g., hearing a voice telling one to lines, callers’ hopelessness and psychological injure or kill oneself) and delusions pain continued to lessen but the intensity of in the context of bipolar disorders their intent to die did not continue to dimin- are related concerns. ish. Moreover, a substantial proportion • Extreme rage (Conner et al., 2003). (43.2%) of the callers continued to express Rage indicates loss of control and suicidal ideation a few weeks after the initial potential for violence, both of which call and nearly 3 percent had made a suicide are common precursors to serious attempt after their call. The callers’ intent to suicidal behavior. die score at the end of the crisis intervention • Increased agitation (Busch, Fawcett, & was the only significant independent predic- Jacobs, 2003). Increased agitation tor of suicidality following the call; although (extreme physical restlessness com- having made any specific plan to hurt or kill bined with emotional turmoil) sug- oneself prior to the call and persistent gests intense psychological pain, suicidal thoughts at baseline were also sig- which as noted above, constitutes an nificant, albeit not independent, predictors important risk factor for suicidality. of any suicidality (ideation, plan, or at- • Decreased sleep (Sabo, Reynolds, tempt). Kupfer, & Berman, 1990). Insomnia Second, neither desire nor capability can lead to mood changes and lack of necessarily imply intent, as evidenced by 360 NSPL Risk Assessment those who have desire and capability but do plains this—the relationship of intent to le- not intend and thus do not attempt or die by thality is qualified by factors like buffers and suicide, often because they are buffered by capability. the factors addressed in the next section (e.g., ties to family and friends). According to the current framework, suicidal intent is made up Buffers Against Suicidality of the following: In almost every suicidal person, there is likely still some will to live. This is demon- • Plan or attempt in progress. This factor strated by numerous instances of suicidal in- is the clearest indicator of intent to dividuals who have survived high lethality at- attempt, in that the attempt is al- tempts and have reported back on their states ready in progress. of mind. For instance, a New Yorker article in • Plan to hurt self/other. Virtually all 2003 quoted a man who had jumped off the risk assessment frameworks empha- Golden Gate Bridge and survived: “I in- size plans for suicide as a key danger stantly realized that everything in my life that sign (e.g., Joiner, Rudd, & Rajab, I’d thought was unfixable was totally fixable— 1999), a practice affirmed by research except for having just jumped.” A man who demonstrating that plans for suicide jumped into the headwaters of Niagara Falls (e.g., method known) represent among in 2003 said that he changed his mind the the most dangerous aspects of suicid- instant he hit the water. “At that point,” he ality ( Joiner et al., 1997, 2003). Plans said, “I wished I had not done it. But I guess to hurt others are relevant too, in I knew it was way too late for that.” He sur- light of the research on violence and vived the plunge over the falls, and now feels aggression noted above. a new lease on life. Harry Stack Sullivan • Preparatory behaviors. Behaviors such (1953) described people who had ingested bi- as arranging the suicide method and chloride of mercury: “One is horribly ill. If leaving possessions to others are one survives the first days of hellish agony, noteworthy for the same reasons that there comes a period of relative convales- imminent plans are. They can be cence—during which all of the patients I viewed as behavioral expressions of have seen were most repentant and strongly imminent plans. desirous of living” (pp. 48–49). (Unfortu- • Expressed intent to die. Stated intent to nately for those patients, another phase of die is a very clear indicator of suicidal several days of agony then resumed eventu- intent. It is common for suicidal be- ally ending in death.) The will to live is ap- haviors to be accompanied by rela- parently powerful enough that it returns even tively low intent to die or ambiva- in people who have suppressed it enough to lence about death. When intent to make a suicide attempt with a high likelihood die is high, the protective aspects of of pain and/or death. For most people, this ambivalence about death are re- will, as well as a number of other factors, moved. Intent to die is a strong pre- usually provides a protective buffer against a dictor of lethality of attempt (Brown, suicide attempt. The CTS identified the fol- Comtois, & Linehan, 2002). lowing buffers based on pragmatic, clinical, and scientific considerations: Suicidal intent deserves considerable weight in a suicide risk assessment, but it should be • Perceived immediate supports. This fac- recognized that some studies have docu- tor is of clear pragmatic impor- mented a low association between intent and tance—callers who are with a sup- lethality of method (e.g., Eaton & Reynolds, portive other will experience the 1985). We believe our framework partly ex- buffering effects of social support as Joiner et al. 361

well as the practical effects of re- typically presents a low-risk-of-suicide sce- moval of means, access to emergency nario. When desire combines with capability care, etc. and/or intent, then suicidal risk may dra- • Other social supports. Lack of access to matically increase and the intervening im- social support is a strong predictor of pact of buffers may enter into the equation. suicidal behavior (e.g., Joiner, 2005); Below are representations of possible com- its presence, by converse, is protec- binations of these factors, but it is important tive. to emphasize that assigning risk status to • Planning for the future. Expressed rea- callers should not interfere with or take pre- sons for living, both in the long-term cedence over establishing empathic contact (e.g., life goals) and the short-term with callers. (e.g., plans to complete a project), Starting with the clearest—and highest have been documented as protective risk—scenario, when suicidal desire, suicidal against suicidal behavior (Strosahl, capability, and suicidal intent are all present, Chiles, & Linehan, 1992). risk is high, and this is essentially true regardless • Engagement with helper (telephone of the presence of buffers. This last phrase is key, worker). This factor is a specific ex- as clinical experience points to many people ample of those more general factors who have died by suicide even in the pres- on social support noted above. It is ence of buffers. When desire is paired with exemplified by elements like open- either intent or capability (but not with ness with and disclosure to the both), risk is lower but still considerable, and worker, as well as the worker’s sense the determination of whether risk is particu- that a collaborative connection has larly high rests with the safety afforded by been established. buffers—if safety is high, risk is more moder- • Ambivalence for living—core values/be- ate (though still elevated and in need of regu- liefs—sense of purpose. This factor, as lar monitoring); if safety is low, risk is ap- well as some reasons for living (i.e., proximately as high as when desire, capability, an ambivalence about death that in- and intent are all present. Suicidal desire is cludes attraction to life; Linehan, best viewed as an indicator of acute distress Goodstein, Nielsen, & Chiles, 1983) or a symptom of a mood disorder, and does and core values/beliefs (e.g., duty to not entail significant risk on its own. Capabil- family, religious beliefs), all represent ity and intent are more pernicious, and here the same process as planning for the again, the safety afforded by buffers is partly future, noted above. Specifically, each determinative. If safety is high, capability of these factors reflects a connection and/or intent do not convey the higher risk to living. categories, but may convey moderate risk and require regular monitoring. If safety is low, Presence of these buffers do not automati- capability and/or intent is a more serious cally offset risk based on suicidal desire, sui- concern, and requires active intervention, cidal capability, and suicidal intent, and, in though probably not to the level of rigor or particular, are of little importance if acute immediacy occasioned by the combinations risk is high, but as will be seen in the next of desire, capability, and intent (see Figure 2 section, they may affect risk calculations in for graphic representation). significant ways. It is important to note that formulat- ing an individual’s risk for suicide is best THE INTERRELATIONS OF THE practiced through a highly collaborative pro- FOUR FACETS, AND ATTENDANT cess, whereby efforts to engage and intervene IMPLICATIONS FOR CRISIS CALLS with the caller are often seamlessly inter- Suicidal desire occurring independent woven throughout the worker’s assessment of suicidal capability and/or suicidal intent process. For example, research has shown 362 NSPL Risk Assessment

Figure 2. that an individual’s self-assessment of suicide and colleagues (both this issue), the “intent risk may outperform clinical judgments to die” assessed at the end of the call was the ( Joiner et al., 1999), suggesting that workers best predictor of the caller’s later suicidality, can further enhance their assessment by ask- indicating that interventions during the call ing the caller to rate his/her own risk of sui- itself can affect the degree to which the caller cide. In the work by Kalafat et al. and Gould is ultimately assessed to be at risk. Joiner et al. 363

IMPLEMENTATION PROCESS tions (Gould et al., 2005). However, as noted OF STANDARDS FOR SUICIDE earlier, research has shown that failure to RISK ASSESSMENT routinely ask hotline callers about suicide can allow for a significant number of suicidal per- In January 2007, the suicide risk as- sons to be missed (see Kalafat et al. and sessment standards became policy for all Mishara et al., this issue). Lifeline network crisis centers. Extensive Lifeline’s administrators recognize that technical assistance will be provided by the a full suicide risk assessment covering all four CTS and Lifeline. Some of these methods core principles will not be appropriate for include: network-wide conference calls; some callers. Therefore, for every Lifeline newsletter articles; e-mail communications; call, Lifeline’s policy will require that tele- sample suicide risk assessment questions and phone workers ask the callers about suicidal- instruments; and individualized assistance ity. The CTS will be recommending that cri- when requested/needed. All network centers sis center staff ask a minimum of three will be required to submit their suicide risk “prompt questions” that, if answered affirma- assessment instrument to the Lifeline Certifi- tively, could prompt a full scale assessment cation and Training Division for review to (e.g., “Are you—or the person you are call- ensure that their tool meets network stan- ing about—thinking about suicide?”). These dards. Centers will also be encouraged to questions will address current suicidal desire, submit examples of suicide risk assessment recent (previous 2 months) suicidal desire, trainings which demonstrate how they have and past suicide attempts. Clearly, it is im- incorporated the standards into their routine portant to elicit current suicidal desire given educational and skill-building activities for that the caller is calling the Lifeline at that crisis line workers. Once reviewed by the specific moment. What is happening in the CTS to ensure adherence to the standards, caller’s life that motivated him/her to reach these examples will be posted and available to out by calling? If the caller denies current all network crisis centers, with the permis- suicidal ideation, inquiring about recent sui- sion of the submitting crisis centers. It is ex- cidal ideation (e.g., past 2 months) may pro- pected that all Lifeline network centers will vide insight into the caller’s emotional state. be in adherence with the new standards by In addition, a caller may feel more ready to late September 2007. acknowledge previous thoughts/behaviors Lifeline is actively promoted nationally rather than to discuss the more immediate as a resource for suicidal persons. Lifeline’s situation. Depending on how the crisis center policy regarding the suicide risk assessment worker responds, discussing previous suicidal standards will require some degree of suicide desire and/or attempts can increase rapport risk assessment on every Lifeline call. As a and trust leading to disclosure of current sui- suicide prevention hotline, it is essential that cidal desire, if present. Inquiring about previ- every Lifeline caller be assessed for suicide ous suicidal attempts also allows for the tele- risk. A common misconception is that asking phone worker to engage the caller in a about suicide might aggravate or upset call- discussion about what happened before, dur- ers, or, in the extreme, “plant the idea in the ing, and after the attempt, which has the po- person’s mind.” Research does not support tential to increase awareness of the caller’s this assumption. A study examining the im- coping skills, reasons for living, and aware- pact of suicide risk questions to at risk-youth ness of available resources. (e.g., impaired from substance abuse, de- Centers can incorporate these stan- pressed, or past history of suicide attempt) as dards and recommendations into their cur- well as a general youth population found that rent risk assessments by simply adding those neither group was distressed nor more sui- subcomponents of the standards that are not cidal following the introduction of the ques- addressed in their assessments; or, by adopt- 364 NSPL Risk Assessment ing an alternative risk assessment instrument assessment and intervention practices, as well that addresses all the subcomponents. The as how the assessment can be utilized in the CTS also recognizes that telephone workers context of collaborating with callers to better conducting risk assessments need not address ensure their safety. each subcomponent in a rote, survey-like In closing, we emphasize that these manner. Often, risk status can be judged guidelines are specific to crisis hotline con- based on clear statements by callers; by their texts, in which factors like appearance and answers or elaborations in response to a few observed behaviors are inaccessible. Further, questions; or by obvious indicators, such as it should be noted that the framework de- an attempt in progress (for example, the scribed herein, though research-based, has caller reporting the ingestion of a lethal dose not itself been empirically evaluated. Relat- of pills). edly, we view these guidelines as current as Lifeline’s Certification and Training of early-mid 2007, but we note that they may Division will offer free (to Lifeline net- evolve as more information on them is gath- worked centers), evidence-informed trainings ered. Indeed, we are planning longitudinal, on how to incorporate the suicide risk assess- empirical work to evaluate and improve the ment questions into the dialogue with a standards, and we encourage others to do so caller. These trainings will also include how as well. to establish rapport with callers to enhance

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