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Assessment Module for Suicide Prevention

From a deficits focus to an assets based recovery oriented assessment

Risk Assessment Module for Suicide Prevention

What is ASSESS?

ASSESS, as the name suggests is the assessment module in PROTECT. It is aimed at getting to know the person in distress and gaining a thorough understanding of their psychological pain. ASSESS hinges on a key mindset shift in mental health professionals, one that focuses on establishing “what matters to you” rather than “what’s the matter with you“. This is relevant to all mental health assessments, but particularly important for those in suicidal distress. It is highly unlikely that one would get suicidal over things that do not matter to them. Establishing this would not only highlight the source of emotional pain but also provide the avenues to capture hope and rebuild a life that is meaningful to the person.

The ASSESS module not only builds on the knowledge and practice of relational safety introduced in the CORE module but also promotes self awareness of key influences on clinical decision making (AWARE). It also provides in depth understanding of the sequence of activities in an assessment, suicide phenomenology, techniques and strategies for empathic interactions, all the way to formulation (DESPAIR) and documentation (NOTES).

Key Principles

  • Assessments have a dual role: elicit meaningful information and capture hope, both are equally important
  • Be AWARE of powerful rationalising forces that influence your decision
  • Develop intentionality while eliciting information, this is key to detecting and supporting those in whom 90% wants to die and only 10% wants to live.
  • Use the DESPAIR formulation to ground risk thresholds and avoid the Creep – Crash – Crawl phenomenon.
  • The more uncertainty there is, the more one should think aloud in the NOTES.

Training Formats

ASSESS and it’s component units are available in a number of training formats:

  • 60 minute stand alone lectures – covers a unit
  • 60 minute lecture series – sequentially covers all units e.g. in lunchtime meetings
  • 90 minute seminars – covers a unit
  • 4 hour masterclass – covers entire ASSESS
  • As part of 1, 2 or 3 day comprehensive courses

Learning Objectives

At the end of the  ASSESS module students will have a thorough understanding of:

  • The different components of an assessment and common pitfalls
  • The ways in which the assessment process, in particular how clinical decision making can get skewed using the AWARE framework
  • The different presentations of suicidal distress and how the assessment process needs to change to accommodate for these
  • The different strategies and techniques to elicit information while maintaining empathy
  • The art of a rapid risk formulation using the DESPAIR format 
  • The skill of documentation using the NOTES framework

Module Content

Summary of topics covered in ASSESS

The first unit in ASSESS, focuses on the assessor. Having a through understanding of self in terms of how one responds when faced with suicidal distress is an essential step in building assessment skills. Attitudes one holds are explored in detail. Following this students are introduced to the AWARE framework to guide their clinical decision making. Building reflective skills to recognise the difference between a rational decision and one that is rationalising is crucial to enhance safety. An assessment is a complex process, including a range of activities that begin with the referral and / or triage. Prior to the assessment, the assessor has to consider the information at hand and then engage with the person based on the presentation. The interaction, collation of information collected, discussion with a colleague (fellow or senior), formulation, decision and action each has its nuances. The unit draws out some of the complexity and pit falls of each activity and helps the student build a natural flow to the assessment exercise.

An assessment is a complex process, including a range of activities that begin with the referral and / or triage. Prior to the assessment, the assessor has to consider the information at hand and then engage with the person based on the presentation. The interaction, collation of information collected, discussion with a colleague (fellow or senior), formulation, decision and action each has its nuances. The second unit draws out brings clarity to the purpose of each action in the assessment sequence and some of the complexity and pit falls. The goal is for the student to build natural flow to the assessment exercise.

The 3rd unit is all about understanding escalating distress and how it presents. Students are guided through the different stages of pre-ideation, ideation, intention, action, post-action and stabilization. Students learn to subtly change the assessment in terms of the dialogue based on whether the interaction is pre-attempt or post-attempt. Students also learn about warning signs and risk factors and which to prioritise. They also gain an understanding of the bio-psycho-social model of  predisposing, precipitating, perpetuating and protective factors.

The fourth unit is all about learning to strike a balance between maintaining empathy while ensuring that one has got all the information they need. The latter might feel intrusive, however with the right techniques, this can be portrayed as a supportive act. Students are taught the pain relief conversation, validity techniques, narrative approach like suicidal story telling and B4-Now. Mental health professionals are good at supporting those in whom 70% wants to die and 30% wants to live, but not so good at detecting those with a 90:10 ratio. The skills in this unit are about detecting the latter group who may consciously or unconsciously mislead an assessor to believe that things are safe.

The penultimate section in ASSESS introduces the students to DESPAIR, a rapid risk formulation tool which ensures that all aspects that needed to be considered in the clinical decision have been covered. The focus is primarily on dynamic factors which not only fluctuate as the risk evolves, but are also potential for intervention. The DESPAIR tool can be used in conversation with the person in distress and or their family as a way of establishing their opinion and engaging them in shared decision making. The tool protects against creep-crash-crawl, a phenomenon in which risk thresholds rise over time due to suicide being a rare event. It also introduces structure and sequence to the process of formulation and discussion with colleagues and helps identify any gaps in the history.

The final unit in ASSESS is on documentation; NOTES. Students are taught how to write comprehensive but precise information that helps guide clinical decisions and provides a clear rational of decisions made. Illustrative examples are provided to help students avoid common minimalist documentation. After providing a narrative description of risk, all options that are considered are documented and the therapeutic intervention that is chosen is clearly justified including an escalation plan and who it is shared with. NOTES builds on DESPAIR and protects both patients and professionals by bringing in rigour while saving time.