Any suspicion that a client is at risk for suicide should be immediately addressed through the use of direct questions. (Have you ever thought that life is not worth living? Have you ever thought about hurting yourself? Do you have a plan to hurt yourself?). If you suspect that a client is suicidal, do not hesitate to ask direct questions to clarify his/her intent.
The primary goal of a suicide assessment is to arrive at a reasonable estimate of the probability that the client will actually attempt suicide in the near future. Your intervention will depend on the level of risk involved. Assessment of suicide risk ordinarily involves both indirect and direct assessment techniques.
Indirect Assessment: Indirect assessment of suicide entails evaluating the client in terms of demographic, clinical, and psychological risk factors that have been consistently linked with a high risk for suicide. Examples of these risk factors include a sense of hopelessness, one or more previous suicide attempts, an absence of social support and social ties, and making preparations for dying (preparing a will, giving away possessions, or saying goodbye to loved ones).
Direct Assessment: Direct assessment of suicide entails questioning the client about his/her intent to die by suicide and emphasizes three indicators that directly suggest and elevated and more imminent risk of a suicide attempt--intent, plans, and means. A communication of intent may be either spoken or written and either direct "I'm going to kill myself") or indirect ("I'm useless and I matter to no one"). All suicide threats should be taken seriously and examined through direct questioning in relation to the client's intention. If the client has communicated an intent, explore the following questions:
Does the client have a suicide plan? If yes, find out whether the plan is specific and concrete. For example, can the client say exactly how when, and where he/she plans to die by suicide? Has the client recently made preparations for death, such as writing a will or giving away his/her possessions?
If the client has a concrete suicide plan, find out whether he/she has the means available to carry out the plan.
The risk to life is highest when the client has both a concrete, lethal suicide plan and the means to carry it out.
Consultation with colleagues is often a very important adjunct when choosing the management strategy for a suicidal client and making treatment decisions. If you are unclear about the meaning of a client's threats or unsure what to do, consult with a colleague and keep notes of the consultation.