People want to get better. Through therapy, we create a space where people can work towards that, where they can be raw, ugly, and honest to claw their way back into the light. As providers, it’s our responsibility to establish trust so clients can feel open to share when they need help.
Suicide prevention relies on people’s honesty and hope. Studies show that when people can openly discuss suicide and their own suicidal feelings, it provides relief and an opportunity to give support for prevention. “Just Ask. You can save a life.” That’s the motto for the Columbia Protocol—known among clinicians as the Columbia-Suicide Severity Rating Scale (C-SSRS).
It’s the same assessment tool we use in our intake form to screen for suicide risk. Though the C-SSRS has a longer version, the star is the shorter version, because it can be used even by people with no mental health training.
The most important indicator of suicide
As part of developing the C-SSRS, the researchers looked at all the factors that determine whether or not someone is at risk of attempting suicide. Filtering those who are at risk from those who aren’t matters for directing limited resources to people who need it but also because taking action with someone wrongly identified as at risk can break trust and cause trauma.
The Columbia Protocol’s researchers spent 5 years thoroughly examining any possible indicators of suicide, from trauma, substance use, planning, self-injury, coping skills, previous attempts, in-patient visits—to name a few.
Past suicide plans that included specifics and intent as well as past suicide attempts were the indicators with the strongest correlation for people attempting in the future or completing suicide.
The C-SSRS is based around the idea of whether a person has a specific plan, means, and intent to commit suicide right now and whether they have attempted it in the past.
A lifesaving tool anyone can use
Along with finding the indicators of suicide, the researchers tested scripts with specific language to identify people who are at immediate risk. We trust the extensive and constantly evolving research behind the Columbia Protocol that proves its effectiveness—which is why we’ve incorporated it into our own intake forms that every new client completes.
Though many providers and professionals may use an in-depth version of the C-SSRS, the project also prioritized creating a brief screener that anyone could use. Today, it’s used by high school students, teachers, clergy, and people looking out for their community, including the Suicide & Crisis Lifeline. Not only is it free to learn and use, anyone can apply the screener without training (though training is necessary for people using the screener for research). However, it can be beneficial: The Columbia Lighthouse Project offers several free trainings, including some that are only 20 minutes.
The screener is made up of 6 questions, each escalating in severity. Below is the simple version of the screener but resources for using more detailed versions are available.
The Columbia-Suicide Severity Rating Scale
Always start with questions 1 and 2. Ask them within the context of either the past month or if working with a client, since their last visit.
- Have you wished you were dead or wished you could go to sleep and not wake up?
- Have you actually had any thoughts about killing yourself?
If the answer to question 2 is ‘yes,’ proceed to questions 3, 4, and 5.
If the answer to question 2 is ‘no,’ skip to question 6.
- Have you been thinking about how you might do this?
- Have you had these thoughts and had some intention of acting on them?
- Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?
Always ask question 6.
- Have you done anything, started to do anything, or prepared to do anything to end your life? (Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, held a gun but changed your mind, cut yourself, tried to hang yourself, etc.)
Any ‘yes’ answers mean that someone should seek behavioral health care.
If someone answers ‘yes’ to questions 4, 5, or 6, they need immediate help. Actions to take include texting or calling the Suicide & Crisis Lifeline at 988, calling 911, going to the emergency room, or using a safety plan. Regardless, stay with this person until they can be evaluated.
Safety plan essentials
Having a safety plan is an industry standard for mental health providers. Again, trust is an essential component for a safety plan. As professionals, we know that calling emergency services and hospitalizing a client can break the trust you and your client have built—but it can also save their life.
Good safety plans establish resources that your client can turn to, before having to escalate.
- Emergency contacts: Besides the provider, who can clients call immediately for support about distressing thoughts? Have your client identify people they can contact and write down their phone numbers.
- Crisis lines: If contacts aren’t available or don’t have the resources to deal with a crisis, provide safety lines such as 211 (mobile crisis units) or 988. Some states and communities such as Virginia also have reliable mobile crisis units that provide 24/7 support, including psychiatry.
As part of our commitment to quality care, we also suggest the following tips for a safety plan that can also help you and your client identify when more help is needed.
- Identify 3 warning signs (thoughts, images, feelings, behaviors) that a suicide crisis is developing, and the safety plan needs to be used.
- Identify 3 things I can do to take my mind off my problems (distracting & calming activities).
- Identify 3 people or social settings (names and phone numbers) that provide distraction.
- Identify social supports (names and phone numbers) who can help handle a suicidal crisis.
- Identify 3 professionals or agencies (names and phone numbers) I contact during a crisis.
- Identify 2 ways I can make the environment safe (removing or limiting access to lethal means).
- Identify: The one thing that is most important and worth living for.
- The provider can also share national resources with the patient if they are experiencing suicidal thoughts or a crisis. The National Suicide Prevention Lifeline is available 24/7 - Dial 988.
Suicide prevention is possible and vital. It requires a bit of vulnerability from all of us, to be honest with answers and to be brave enough to voice important questions. “Just ask. You can save a life.”