July/August 2021

Youth SAVE
Calling in for Care: Best Practices for Telehealth Administrations of Adolescent Suicide Assessments

By Robyn E. Metcalfe, University of Oregon, Department of Counseling, Family, and Human Services; Sarah G. Spafford, University of Oregon, Department of Counseling, Family, and Human Services; Amber Ziring, Oregon Pediatric Society

In Oregon, suicide is the leading cause of death among young people, comprising 37.5% of all deaths in youth aged 15 to 24 and 21.0% of all deaths in those aged 5 to 14 (Oregon Health Authority, 2018). Oregon’s youth suicides have increased at a disproportionately high rate over the past decade. In response to rising rates of youth suicide in the state, the Oregon Health Authority developed a Youth Suicide Intervention and Prevention Plan (YSIPP) as well as postvention services to provide assistance after a death by suicide based on Oregon State Legislature guidance (Oregon Health Authority, 2016.).

Meanwhile, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), widely known as Coronavirus Disease 2019 (COVID-19), has led to dramatic changes in the practice of professional psychology on a global scale, with many psychotherapy settings rapidly adjusting their practices to include primarily or entirely telehealth-based services (Silver et al., 2020). Clinicians have reported numerous concerns about use of telehealth with clients who are suicidal, including concerns about their ability to offer high-quality suicide assessments, lack of control over the client’s behavior, and ability to adequately triage clients (Gilmore & Ward-Ciesielski, 2019). The confluence of these factors increases the urgency of clear standards of practice for suicide assessment via telehealth for practicing psychologists.

In alignment with the goals of the YSIPP and to meet the growing needs of clinicians working within this new, virtual landscape of mental health, the Oregon Pediatric Society has developed a virtual suicide risk assessment and intervention training for Oregon-based youth-serving mental health professionals: Youth Suicide Assessment in Virtual Environments (Youth SAVE). The aim of this training is to equip school- and community-based mental health professionals to virtually assess for and intervene with youth experiencing thoughts of suicide. Youth SAVE guides clinicians through considerations of the virtual context, including multiple forms of communication (e.g., Zoom, phone, text), helping an adolescent share their concerns when confidentiality is limited, and planning for safety. The intervention is relationship focused and youth-centered.

It is vital to remember the impact racism and systemic inequities have on an adolescent’s baseline experience within the community and potential mental health challenges. Youth SAVE provides a framework that reminds practitioners that identities do not intrinsically increase risk, but rather the manner in which an adolescent’s environment responds to those identities creates both positive and negative impact factors that can influence an individual’s risk for suicidality. Integrating this equity framework into clinical practice requires the clinician to acknowledge that youth’s intersecting identities directly impact their experience with mental health treatment. Identities including race, gender, and sexual identity are impact factors that can radically affect the experience that many clients have with suicidality, access to care, and exposure to unhelpful or harmful suicide prevention strategies. Collaborative and equitable suicide prevention strategies are vital to creating a deeper understanding of the ways that young people’s mental health needs are rooted in interpersonal, contextual, and ecological experiences, including racism, sexism, homophobia, transphobia, xenophobia, poverty, colonialism, and other forms of oppression.

A commonly held fear among clinicians is that asking a client about suicidal thoughts will induce or exacerbate suicidality, suggesting that discussion of suicide may put the idea of suicide in a client’s mind. However, research has suggested that asking about suicide instead reduces suicidal ideation and can lead to improvements in mental health status (Dazzi et al., 2014; Mathias et al., 2012. It is not only acceptable, but also encouraged for mental health providers to regularly discuss and assess a client’s suicidal ideation as a key component of treatment when applicable.

A number of important cues can demonstrate that suicide assessment is warranted. In particular, clinicians should carefully attend to comments that allude to a lack of future, statements that demonstrate feelings of hopelessness or helplessness, reports of unbearable pain, and disclosures such as “I have no reason to live,” “I just don’t want to be here anymore,” or “They would be better off without me.” Clinicians should also watch for cues such as withdrawal, increases in substance use or other risky behaviors, sleep or appetite changes, aggression, fatigue, and saying ‘goodbye’ or giving away possessions.

Use of standardized assessment measures has the potential to offer substantial benefit to practicing clinicians. Many psychologists ask clients if they have suicidal thoughts, but do not continue on from there to conduct a comprehensive assessment (Smith, 2014). The use of empirically based assessment tools allows for more comprehensive and structured practice for suicide assessment. One empirically-validated free tool for general clinical use is the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011), which assesses severity of ideation, intensity of ideation, behavior, and lethality. The C-SSRS can be used as a semi-structured interview. Printable cards of the C-SSRS are available for free on the Lighthouse Project Website (https://cssrs.columbia.edu).

The C-SSRS begins with two items:

  1. Have you wished you were dead or wished you could go to sleep and not wake up?
  2. Have you actually had any thoughts about killing yourself?

If the answer to item 2 is “no”, the clinician may skip questions 3 through 5 and proceed to question 6. If the answer is “yes”, the clinician next asks question 3:

  1. Have you thought about how you might do this?
  2. Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them?
  3. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

No matter the client’s responses to the above questions, they will always ask question 6 (a minimum of three questions for this screener).

  1. Have you done anything, started to do anything, or prepared to do anything to end your life?

Given the predictive validity of the C-SSRS and its ease of administration (Gipson et al., 2015), it is likely to offer substantial benefit over unstructured alternatives. While the C-SSRS has not been validated with non-dominant culture groups in the United States, it allows for a clinician to adapt the questions to serve their client’s unique needs without impacting the validity of the screener. When clients score as low-risk on the C-SSRS, it may be warranted to schedule regular check-ins and identify sources of support system and resiliency factors. When clients score as high-risk on the C-SSRS, it may be warranted to develop a safety plan and immediate referrals to services. Clinicians may also consider tools such as Ask Suicide-Screening Questions (ASQ), the Patient Safety Screener (PSS-3), and the Patient Health Questionnaire (PHQ-9).

After an initial suicide assessment, it may be clinically warranted to create a safety plan with a client. Safety plans are a list of coping strategies and support resources for clients to use preceding or during an incident of acute suicidality to aid in emotion regulation and/or physical safety (Stanley & Brown, 2008). Higher quality safety plans are associated with a decreased risk of subsequent psychiatric hospitalization (Gamarra et al., 2015), suggesting the importance of creating a comprehensive and clear safety plan when suicidal risk is present. Ideal safety plans are collaboratively developed, youth-centered, and strengths-based, while also being both realistic and flexible for the client’s context (Ziring et al., 2020). The Oregon Pediatric Society safety plan template is available here: https://tinyurl.com/y58bz7bs. A practicing clinician may choose to adapt this resource in advance of a crisis to input their own relevant local resources. Importantly, a safety plan that is not usable by a client is not likely to be effective. Including the client in every step of the process and assessing for potential barriers or obstacles are also important components of this process.

Assessing and documenting access to lethal means is always an important piece of risk management for any suicide assessment or safety plan. Parents often underestimate the access that their children have to firearms and other risky items (Baxley & Miller, 2006). For an adolescent, it may be appropriate to conduct part of lethal means assessment using a caregiver report. At a minimum, a clinician should assess access to lethal means, including firearms and toxic medication, in addition to access to other hazards that are idiosyncratic to a client’s suicide plan. If lethal means are identified, reducing access to these means is an integral part of safety planning. Although lethal means counseling is inconsistently used in general clinical practice (King et al., 2018), caregivers of adolescents show high compliance for behaviors such as locking up medication and firearms when these interventions are used (Runyan et al., 2016). Additional lethal means management strategies and information are available from the Harvard School of Public Health: https://www.hsph.harvard.edu/means-matter/. The SLAP acronym can also be used to help assess risk: Specificity, Lethality, Availability of Means, and Proximity to Helping Resources (National Center for Youth Issues, 2018).

When risk of suicide is a concern for a client, a process for ongoing assessment and management is essential. For example, the Collaborative Assessment and Management of Suicidality (CAMS) is one powerful therapeutic framework for suicide-specific assessment and treatment in adolescents (Jobes et al., 2019). The Suicide Status Form (SSF‐IV), the primary assessment measure and treatment planning tool within the CAMS framework, has been validated without adaptation in an adolescent psychiatric sample (Brausch et al., 2019). An example SSF-IV form is available on the CAMS website: https://cams-care.com/wp-content/uploads/2018/03/Completed-SSF-4.pdf. Notably, effective CAMS administration builds in a strengths-based approach while taking a client’s suffering seriously. Other strengths-based resources, such as Marsha Linehan’s Brief Reasons for Living Inventory for Adolescents (BRFL-A; Osman et al., 1996) may also be appropriate to incorporate.

Fundamentally, suicide assessments are relational conversations in nature (Flemons & Gralnik, 2013). Thus, a clinician’s ability to convey empathic understanding is core to effective risk management. Core helping skills are essential, including reflective listening, resisting the righting reflex, and OARS skills (open ended questions, affirmations, reflections, and summaries).

Importantly, clinicians working with adolescents should prepare in advance of an incident involving acute suicidal risk to ensure that they have access to appropriate resources. For example, clinicians may choose to:

  1. Review their organizational policies related to home visits.
  2. Ensure that they have adequate contact information for adolescent clients (e.g. current addresses and locations, caregiver contact information).
  3. Review their legal and ethical obligations related to mandatory reporting of imminent risk to self.
  4. Maintain accurate information about local procedures for client welfare checks.
  5. Maintain contact information about local community crisis teams (e.g. the Washington County Crisis Team, White Bird Crisis Services/CAHOOTS).
  6.  Review the scope of Oregon-based services, such as Lines for Life (800-273-8255) and national population-based services (e.g. The Trevor Project, Trans Lifeline, Crisis Text Line, National Parent Helpline, Deaf Hotline, National Sexual Assault Hotline, and Strong Hearts Native Helpline).
  7. Confirm referral processes for intensive outpatient services offering evidence-based programs for suicidality (e.g. Dialectical Behavior Therapy) and residential treatment services.
  8. If operating in a setting that employs Community Resource Officers (CROs; i.e., a school), evaluate their approach to students. For example, is their approach relational or enforcement-based? What relationship do CROs have with uniformed community police officers? CROs may be viewed as an appropriate authority or a traumatic figure depending on the adolescent’s community or identities. When unable to reach an adolescent, a CRO is likely preferable to other law enforcement, unless the clinician is aware of the adolescent having a contentious relationship with the CRO. 
  9. Discuss general risk management strategies with a supervision or consultation group. For example, consider practices to minimize the risk of coercion and improve client-centered care in the case of a hospitalization. Notably, perceived coercion during inpatient admission may increase suicidal risk (Jordan & McNiel, 2019).

Although suicide assessment over telehealth poses unique challenges for clinicians working with adolescents, the best available evidence suggests that it can be done effectively and ethically (McGinn et al., 2019). Adequate planning for high risk incidents and use of evidence-based practices combined with important clinical skills to build and maintain rapport can help increase positive and safe outcomes for the youth of Oregon. Clinicians working with adolescents via telehealth should prepare immediately to increase their ability to engage in effective assessment and intervention strategies. 

Content for this article was made possible by a collaborative effort between the Oregon Pediatric Society and the Mental Health Promotion and Suicide Prevention Lab at the University of Oregon. Youth Suicide Assessment in Virtual Environments (Youth SAVE) Trainings, created through a partnership between Oregon Pediatric Society, Association of Oregon Community Mental Health Program, and Oregon Health Authority, will be available for free in 2021 and beyond. For more information, please visit https://oregonpediatricsociety.org/youth-save/. 

References

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