PAC 410 Module 2 Suicide Assessment and Intervention Example

Two Guns in the Closet: Suicide Assessment Without Prediction, Safety Planning and Means Restriction on a Crisis Text Line

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Psychology and Addiction Studies Program, Aspen University

PAC 410: Crisis Intervention and Prevention

Instructor Name

Month Day, Year

Two Guns in the Closet: Suicide Assessment Without Prediction, Safety Planning and Means Restriction on a Crisis Text Line

At one in the morning on a Saturday, a text arrived at the crisis line run by Hudson Valley Crisis Services, the invented team in these papers. The writer, who later gave his name as Darius, was nineteen and a freshman at a nearby college, home for the weekend. His girlfriend of two years had ended the relationship that evening. He had drunk six beers alone in his room. "I don't see the point of anything," he wrote. Later in the conversation he mentioned that his father keeps two handguns in a closet. This paper describes the assessment and intervention. Darius and his father are fictional, as is the text line, though every finding the counselor relied on comes from published research.

Why Prediction Is Not the Goal

Franklin et al. (2017) conducted a meta-analysis of studies published over fifty years that examined risk factors for suicidal thoughts and behaviors, including depression, prior attempts, substance use and many others. Across hundreds of studies, risk factors predicted later suicidal thoughts, attempts and deaths only slightly better than chance. No broad category of risk factor was substantially better than others, and predictive ability had not improved over the decades. The authors concluded that the field's approach of identifying risk factors had not produced accurate prediction and called for new approaches.

For a crisis counselor, the finding has a clear implication. A checklist of risk factors cannot tell whether Darius will act tonight. Every person who expresses suicidal thinking needs a careful response, focused on safety, connection and follow-up, rather than a calculation that sorts people into high and low risk and leaves some without help.

Asking Directly

Counselors sometimes hesitate to ask about suicide for fear of planting the idea. Gould et al. (2005) tested this concern in a randomized trial in high schools. Students were randomly assigned to complete a survey that included questions about suicidal thoughts and behavior or one that did not. Students asked about suicide did not show more distress or more suicidal thinking afterward than those who were not. Among high-risk students, those with depression, substance problems or past attempts, those who were asked actually reported less distress. Asking directly is safe and necessary.

The Contact

Alcohol and the Next Few Hours

Darius had drunk six beers in about two hours. Alcohol matters in suicidal crises for reasons that are immediate, not long term. It loosens inhibition, narrows attention to the present pain and makes impulsive acts more likely, which is why intoxication is treated as a sign of immediate danger in crisis work. It also means that how Darius feels at one in the morning is not how he will feel at noon. The counselor's goal for the night was therefore simple: get him through the next several hours safely, with the guns out of reach, no more alcohol and another person awake with him, so that the decisions about what comes next could be made sober.

Means Restriction

Yip et al. (2012) reviewed evidence on restricting access to means of suicide, such as firearms, pesticides, medications and jumping sites. Restricting access to a common method reduced suicides by that method, and in many cases reduced overall suicide rates, because many suicidal crises are brief and people often do not substitute another method when one is unavailable. The authors concluded that means restriction is one of the most effective suicide prevention strategies.

For Darius, the guns were the most urgent concern. Firearms are highly lethal, and he was intoxicated. With his permission, the counselor asked Darius to wake his father. His father came to the phone, and the counselor explained the situation and asked him to remove the guns from the house that night. His father placed them in his car, locked it and kept the keys, and agreed to take them to his brother's house the next day.

The Safety Plan

Stanley et al. (2018) tested the safety planning intervention in emergency departments in a large study comparing it with usual care. Patients who received a safety plan, written collaboratively with them, plus at least two structured follow-up telephone calls after discharge, had nearly half as much suicidal behavior over six months as patients receiving usual care, and more of them went on to see an outpatient mental health clinician. The follow-up calls were an essential part of the intervention.

Darius and the counselor wrote a brief safety plan by text. His warning signs were drinking alone and rereading old messages. His coping steps were to put his phone in another room and watch something with his sister. His people to contact were his friend Andre and his father. His professional contacts were the crisis line, 988 and the college counseling center. His safe environment step was that the guns were out of the house and he would not drink more that night. Before ending the contact, the counselor confirmed that his father would stay up with him.

Follow-Up

The next afternoon, as agreed, a counselor from the team called Darius. He was hungover and embarrassed but safe, and the guns had been taken to his uncle's. The counselor reviewed the safety plan, discussed his drinking and helped him make an appointment with the college counseling center for the following Monday. A second call was scheduled for the end of the week.

Conclusion

Darius's crisis combined a painful loss, alcohol and access to firearms. Franklin and colleagues show that no risk score could have told how dangerous his night was, Gould and colleagues show that asking him directly was safe, Yip and colleagues show why removing the guns mattered most and Stanley and colleagues show that a safety plan with follow-up calls reduces suicidal behavior. The contact addressed each, and the follow-up continued what the night began.

References

Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Musacchio, K. M., Jaroszewski, A. C., Chang, B. P., & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187-232. https://doi.org/10.1037/bul0000084

Gould, M. S., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: A randomized controlled trial. JAMA, 293(13), 1635-1643. https://doi.org/10.1001/jama.293.13.1635

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776

Yip, P. S. F., Caine, E., Yousuf, S., Chang, S.-S., Wu, K. C.-C., & Chen, Y.-Y. (2012). Means restriction for suicide prevention. The Lancet, 379(9834), 2393-2399. https://doi.org/10.1016/S0140-6736(12)60521-2