Suicidal concerns are not limited to counselors, therapists and mental health professionals. Suicides occur in all facets of society. Suicide occurs among students, defendants, probationers, inmates, patients, juveniles and adults. Other high suicide risk groups include gamblers, substance (alcohol and other drugs) abusers, victims and high stress individuals. Caregivers and supervisory personnel are becoming aware of the need to include a suicide screen in their intake and screening procedures.
Suicide Evaluation is a suicide screen or test designed to help identify suicidal individuals. Suicide Evaluation is a self-report test that consists of 140 items and takes 25 to 30 minutes to complete. Suicide Evaluation is scored on your computer and reports are printed within 2½ minutes on-site.
SIX SUICIDE EVALUATION SCALES (MEASURES)
Truthfulness Scale: measures how truthful the client was while completing the test. This scale identifies denial, guardedness, problem minimization, and attempts to "fake good." It is important to know how truthful the client was while completing the Suicide Evaluation.
Suicide Scale: measures a person's propensity to commit suicide. When suicidal people do not get help early the probability of a suicidal act increases dramatically. Real prevention is only possible if other people recognize the signals in time.
Depression Scale: measures loss of interest or pleasure in usual activities, agitation, insomnia, significant weight loss, and feelings of worthlessness, insomnia, melancholy, unhappiness, etc. Severe depression is often associated with suicidal acts.
Alcohol Scale: measures the severity of alcohol use and abuse. Alcohol refers to beer, wine and other liquors. Alcohol is a licit substance. Alcohol is all too frequently involved in suicidal acts.
Drugs Scale: measures drug use and the severity of abuse. Drugs refer to marijuana, crack, cocaine, amphetamines, methamphetamines, barbiturates, heroin, etc. The literature suggests that drugs are increasingly involved in suicidal acts.
Stress Coping Abilities Scale: measures a person's ability to cope with stress and perceived pressure. Stress, when not properly handled, exacerbates mental health symptomatology. This scale is a non-introversive screen for acute and prolonged (established) emotional and mental health problems.
Suicide Evaluation is a concise, yet comprehensive suicide screening procedure (test) that can be incorporated into most intake procedures for clients, patients, probationers, inmates, and others. Including a suicide screen in one's intake can enhance patient care, reduce liability, and facilitate appropriate intervention. In brief, Suicide Evaluation is an automated (computer scored) assessment instrument or test that helps identify suicidal individuals. Suicide Evaluation should be used in conjunction with a client interview and review of available records. The importance of screening should not be minimized.
Suicide Evaluation screening filters out individuals with suicidal predispositions. This filtering system works as follows:
Reference to the above table shows that a "problem" is not identified until a client's scale score is at or above the 70th percentile. These risk range percentiles are based upon people that have taken the Suicide Evaluation. People scoring in the 70 to 89th percentile range are problematic. People scoring in the 90 to 100th percentile range represent severe suicide problems. Suicide Evaluation enables assessors, evaluators, and screeners to match suicide problem severity with treatment intensity. In other words, suicidal individuals can be identified and referred to appropriate treatment programs. Early problem identification combined with prompt intervention results in more effective treatment outcomes.
Selecting a Suicide Test
UNIQUE SUICIDE EVALUATION FEATURES
Truthfulness Scale: Identifies denial, problem minimization, and faking. A Truthfulness Scale is a necessary component in contemporary tests. The Truthfulness Scale has been validated with the Minnesota Multiphasic Personality Inventory (MMPI), polygraph exams, other tests, truthfulness studies and experienced staff judgment. The Truthfulness Scale has been demonstrated to be reliable, valid, and accurate. In some respects the Truthfulness Scale is similar to the MMPI's L and F-Scales. It consists of a number of items that most people agree or disagree with.
Truth-Corrected Scores: Have proven to be very important for assessment accuracy. This proprietary truth-correction process is comparable to the MMPI K-Scale correction. The Suicide Evaluation Truthfulness Scale has been correlated with the other 5 scales. The Truth-Correction equation then converts raw scores to Truth-Corrected scores. Truth-Corrected scores are more accurate than raw scores. Raw scores reflect what the client wants you to know. Truth-Corrected scores reveal what the client is attempting to hide.
Four ways to give the Suicide Evaluation. The Suicide Evaluation can be administered in four different ways: 1. Paper-Pencil test booklet format is the most popular testing procedure. English and Spanish test booklets and answer sheets are available. 2. Tests can be given directly on the computer screen (in English and Spanish). 3. Human voice audio is also available in English or Spanish. This involves a headset or speakers. The client uses the up-down arrow keys. As the client goes from question to answer with the arrow keys that question or answer is highlighted on the monitor and concurrently read to the client. And 4. Testing over the internet at www.online-testing.com. Each test administration mode has advantages and some limitations. BDS offers these four test modes so test users can select the administration mode that is optimally suited to their needs.
Reading Impaired Assessment: Reading impaired suicidal clients represent 20+ percent of the offenders tested. This represents a serious problem to other suicide tests. BDS has developed an alternative for dealing with this problem, Human Voice Audio.
Human Voice Audio: presentation of the Suicide Evaluation in Human Voice Audio is in English and Spanish. Client's passive vocabularies are often greater than their active vocabularies. Hearing items read out loud often helps reduce cultural and communication problems. This administration mode requires earphones and simple instructions to orient the client to the up-down arrow keys on the computer keyboard. Human Voice Audio is an alternative approach for screening reading impaired clients.
Confidentiality: BDS encourages test users to delete client names from diskettes before they are returned to BDS. Once client names are deleted they are gone and cannot be retrieved. Deleting client names does not delete demographics or test data which is downloaded into the Suicide Evaluation database for subsequent analysis. This proprietary name deletion procedure involves a few keystrokes and insures client confidentiality and HIPAA (federal regulation 45 C.F.R. 164.501) requirement compliance.
Test Data Input Verification: Allows the person that inputs test data from the answer sheet into the computer to verify the accuracy of their data input. In brief, test data is input twice and any inconsistencies between the first and second data entry are highlighted until corrected. When the first and second data entry match or are the same the staff person can continue. This proprietary Data Input Verification procedure is optional, yet strongly recommended by BDS.
Inventory of Scientific Findings: Much of the Suicide Evaluation research has been gathered together in a document titled "Suicide Evaluation: An Inventory of Scientific Findings." This document summarizes Suicide Evaluation research chronologically - as the studies were completed. This chronological reporting format was established largely because of the Suicide Evaluation database which permits annual database analysis of all tests administered.
Orientation and Training Manual: The Suicide Evaluation Orientation and Training Manual (O&T Manual) explains how the Suicide Evaluation works. It is a must read for staff that will be using the Suicide Evaluation. O&T Manual content includes, but is not limited to, the following: instructions for testing, explanation of how scores are derived, clarification of how court-related information is used, description of unique Suicide Evaluation features and much more.
Staff Training: BDS staff is available to participate in Suicide Evaluation training programs conducted by statewide programs, departments, and high volume agencies in the United States. Sometimes smaller volume providers get together for collective (multiple providers) on-site training. BDS typically participates in 4 hour or 6 hour Suicide Evaluation training sessions. This training can include hands-on computer scoring as desired. Attendees often receive continuing education credits (CEU's) for the time involved. BDS gives attendees certificates attesting to their Suicide Evaluation training.
Free Examination Kit: A 1-test DRI-II demonstration diskette is available on a 30 day cost free basis. Demo diskettes are in Windows format, a one-time setup procedure is required. This free examination kit has a 1-test demo diskette, test booklet (reusable), an answer sheet (can photocopy), an Orientation and Training Manual, Installation CD (with instructions) and some descriptive information. BDS does want the demonstration diskette, CD and test booklet returned within 30 days.
SUICIDE EVALUATION SCALE INTERPRETATION
The following is a starting point for interpreting Suicide Evaluation scale scores.
A problem is not identified until a scale score is at the 70th percentile or higher. Elevated scale scores refer to percentile scale scores that are at or above the 70th percentile. Problem Risk (70 - 89th percentile) scale scores are "problematic" in the sense that the client is experiencing difficulties in the area represented by that scale. For example, on the Suicide Scale that client is experiencing some suicidal ideation and this scale score can be exacerbated by other elevated Suicide Evaluation scale scores. Severe Problem (90 - 100th percentile) scale scores represent extreme or critical problems. With regard to the Suicide Scale, severe problem (90 - 100th percentile) scorers need prompt and intensive assistance. Such scores should not be ignored. Other elevated scale scores can represent exacerbation of an already perilous and dangerous situation.
1. Truthfulness Scale: measures how truthful the respondent was while completing the test. This scale identifies guarded and defensive people who attempt to minimize their problems and "look good." Truthfulness Scale scores at or below the 89th percentile mean that the client was truthful and all Suicide Evaluation scales are accurate. Truthfulness Scale scores in the 70 to 89th percentile range are accurate because they have been Truth-corrected. Scores at or above the 90th percentile means that all Suicide Evaluation Scale scores are inaccurate (invalid) because the client was overly guarded, read things into test items that aren't there, was in denial, or was minimizing their problems. Respondents with reading impairments might also have elevated scores. If not consciously deceptive, respondents with elevated Truthfulness Scale scores are uncooperative, fail to understand test items or have a need to appear in a good light.
The Truthfulness Scale score is important because it shows whether or not the respondent answered Suicide Evaluation items honestly. Truthfulness Scale scores at or below the 89th percentile indicate that all other Suicide Evaluation scale score are accurate. One of the first things to check when reviewing a Suicide Evaluation report is the Truthfulness Scale score. The Truthfulness Scale score takes precedence over all other Suicide Evaluation Scale scores. The Truthfulness Scale can be interpreted independently or within the context of how it affects other Suicide Evaluation Scale scores.
2. Suicide Scale: identifies suicide prone individuals. In almost every act of suicide, there are hints of suicidal thinking before the suicidal act occurs. One of the major obstacles in suicide prevention is not remediation, rather it is in identification. Most individuals that are contemplating suicide are acutely aware of their intentions. Yet, on the other hand the suicidal person may be unaware of their own lethality. Nonetheless, suicidal people usually give many hints of their intention. Suicide literature suggests that most suicidal acts often stem from a sense of emotional isolation and some intolerable emotion. Many believe suicide is an act to stop an intolerable existence. Unfortunately, each of us defines "intolerable" in our own way. Still, in almost every case there are precursors to suicide. Recognizing these clues is a necessary first step in suicide prevention.
The Suicide Scale assesses verbal clues such as "I can't stand it any more" and behavioral clues like increasing successive approximations with suicidal instruments like razors, pills and moods like depression. An elevated Truthfulness Scale score can reflect early symptoms of emotional detachment, defiance and withdrawal. Substance (alcohol and other drugs) abuse is often associated with the suicidal act. It's like striving for numbness of mind, a non-think state that can facilitate an impulsive act. A person's attitude, particularly if resistant and negativistic can foreshadow emotional isolation, internalization and "giving up." Although depression is the most recognized syndrome for suicide, it is not the only one. Consequently, the presence of emotional or mental health problems (Stress Coping Abilities Scale) should not be ignored.
To accurately identify suicidal individuals, we must combine separate symptoms when no symptom by itself would necessarily be a good suicide predictor. And, to a large extent, that is what the Suicide Evaluation does. When you have an elevated Suicidal Scale score with another elevated Suicide Evaluation scale score, the assessor should consider the exacerbating effect of the other elevated scale. When the Suicide Scale score is in the severe problem (90 to 100th percentile) range the assessor must consider suicide a possibility and take the appropriate steps. The higher the scores, the more serious the situation. The more elevated scale scores, the more serous the prognosis.
Appropriate steps may include alerting other staff, obtaining a consultation, promptly referring the client to a licensed mental health professional, referring the client to a mental health professional that specializes in suicide assessment/treatment, or requesting a comprehensive psychological evaluation that incorporates suicide risk. There are many other referral, assessment and treatment options. The assessor's experience and judgment will influence decisions involving the client's family, friends, and support group.
An elevated Suicide Scale is particularly unstable when accompanied by an elevated Depression Scale score and/or an elevated Alcohol or Drugs Scale score. Such a profile is particularly perilous and defines high risk. The higher the elevation of these scales, the worse the prognosis. The Suicide Scale can be interpreted independently or in combination with other Suicide Evaluation Scales.
3. Depression Scale: measures dejected or self-depreciating emotional states that vary from normal to pathological (severe). Melancholy, dysphoria, and sadness are incorporated under the term "depression." An elevated (70 to 89th percentile) Depression Scale score identifies emerging depression symptoms like depressed mood, diminished interests or pleasure, insomnia, fatigue or loss of energy, low self-esteem, feelings of worthlessness, hopelessness and difficulty concentrating. Other symptoms include social withdrawal, brooding, irritability, etc. An elevated (70 to 89th percentile) Depression Scale score identifies emerging depression. Symptoms are evident but not necessarily chronic nor intense. In High Risk or Severe Risk (90 to 100th percentile) scorers symptoms are more pronounced and of a chronic nature. During these periods clients usually appear sad or "down in the dumps."
Depression has been identified in the psychological literature as a common factor found in most suicides. When an elevated (70 to 89th percentile) Depression Scale score accompanies an elevated Suicide Scale score that client is at risk. And the higher these scale scores are the worse the prognosis. Depression is an important factor in suicide prediction.
Other elevated (70 to 89th percentile) Suicide Evaluation scale scores include the Alcohol Scale and the Drugs Scale. When combined these scales are often referred to as substance abuse and substance abuse is another important factor in suicide prediction. Elevated Alcohol Scale, Drugs Scale, Depression Scale, and Stress Coping Abilities Scale scores are a malignant sign. The presence of any of these elevated Suicide Evaluation scale scores with an elevated Suicide Scale score increase the probability of suicide dramatically. Substance-induced mood disorders might be discussed as "substance (alcohol and other drugs) abuse problems and their relationship with the Depression Scale in suicide prediction. They are contributing factors.
The Depression Scale can be interpreted independently. However, an elevated (70 to 89th percentile) Depression Scale score should be interpreted in combination with the Suicide Scale when both are elevated.
4. Alcohol Scale: measures alcohol use and the severity of abuse. Alcohol refers to beer, wine or other liquors. An elevated (70 to 89th percentile) Alcohol Scale score is indicative of an emerging drinking problem. An Alcohol Scale score in the Severe Problem (90 to 100th percentile) range identifies established and serious drinking problems. Elevated alcohol Scale scores do not occur by chance.
A history of alcohol problems could result in an abstainer (current non-drinker) attaining a Low to Medium Risk Alcohol Scale score. Consequently, safeguards have been built into the Suicide Evaluation to identify "recovering alcoholics." For example, item number 114 asks if the client is a "recovering alcoholic." Other alcohol admissions include #21, 31, 36, 47, 52, 113, 114, 123, and 129. More specifically, item 47 states "I have a drinking problem," and # 129 states "I am an alcoholic." The client's admission to any of these items is printed on page 3 of the report, under the "Significant Items" heading for easy reference. In addition, elevated Alcohol Scale risk paragraphs (Suicide Evaluation report) caution staff to establish if the client is "recovering." If recovering, how long?
Severely elevated Alcohol and Drugs Scale scores indicate polysubstance abuse, and the highest score usually identifies the offender's substance of choice. Scores in the severe problem (90 to 100th percentile) range are a malignant prognostic sign. Elevated Alcohol Scale and Suicide Scale scores identify a particularly dangerous or suicide prone individual. Here we have a suicidal individual that is even further impaired when drinking. Alcohol abuse exacerbates suicidal thinking is suicide prone individuals.
In assessment and treatment settings the Alcohol Scale score can help staff work through denial. More people accept objective standardized assessment results as opposed to someone's subjective opinion. This is especially true when it is explained that elevated scores do not occur by chance. The Alcohol Scale can be interpreted independently or in combination with other Suicide Evaluation scales.
5. Drugs Scale: measures drug (marijuana, ice, crack, cocaine, amphetamines, barbiturates, heroin, etc.) use and severity of drug abuse. An elevated (70 to 89th percentile) Drugs Scale score identifies emerging drug problems. A Drugs Scale score in the severe problem (90 to 100th percentile) range identifies established drug problems and abuse.
A history of drug-related problems could result in an abstainer (current non-user) attaining a Low to Medium Risk Drug Scale score. For this reason precautions have been built into the Suicide Evaluation to identify "recovering" drug abusers. Some of these precautions are similar to those discussed in the above Alcohol Scale description. The client's answer to the "recovering drug abuser" question (item 114) is printed on page 3 of the Suicide Evaluation report. Other drug abuse admission items include #18, 23, 43, 60, 68, 73, 81, 115, and 132. More specifically item 23 states "I use and sometimes abuse drugs." Item 60 states "I have a drug abuse or drug-related problem." And item 115 (1) "Drug use is a serious problem." The client's admission to any of these items is printed on page 3 of the Suicide Evaluation report under the "Significant Items" heading for easy reference. In addition, elevated Drugs Scale risk paragraphs (Suicide Evaluation report) caution staff to establish if the client is "recovering." If recovering, how long?
Concurrently elevated Drugs and Alcohol Scale scores are indications of polysubstance abuse, and the highest score reflects the client's substance of choice. Very suicidal clients are identified when both the Drugs Scale and the Suicide Scale are elevated. Any Drugs Scale score in the severe problem (90 to 100th percentile) range should be taken seriously. And Suicide Scale scores can be exacerbated when the client is abusing drugs. The Drugs Scale can be interpreted independently or in combination with other Suicide Evaluation scales.
6. Stress Coping Abilities Scale: measures the client's ability to cope effectively with stress, tension, and pressure. How well a person manages stress effects their overall adjustment. A Stress Coping Abilities Scale score in the elevated (70th percentile and higher) range provides considerable insight into co-determinants. When considered individually such scores can suggest possible intervention or treatment programs like stress management, lifestyle adjustment, or supportive counseling.
A client scoring in the Severe Problem (90 to 100th percentile) range on the Stress Coping Abilities Scale should be referred for further evaluation. We know that stress exacerbates emotional and mental health problems. The Stress Coping Abilities Scale is a non-introversive way to screen for established (diagnosable) mental health problems.
A particularly unstable situation involves an elevated Stress Coping Abilities Scale with an elevated Suicide Scale score. Poor stress coping abilities along with substance (alcohol and other drugs) abuse in a suicide prone individual defines high suicide risk. The higher the elevation of these scales -- the worse the prognosis. The Stress Coping Abilities Scale can be interpreted independently or in combination with other Suicide Evaluation scales.
In conclusion it was noted that several levels of Suicide Evaluation interpretation are possible. Suicide Evaluation scale interpretations range for using Suicide Evaluation scales independently to interpreting scale elevations and inter-relationships. Most clinically oriented assessors and therapists interpret scale inter-relationships within the context of the client's life situation.
To review a Suicide Evaluation example report, click on this Example Report link.
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