The Suicide Risk Scale enables clinicians to adopt an evidence based suicide risk scale, which is based on M. David Rudd’s (2006) suicide theory. In addition to calculating suicide risk, this scale identifies suicide problem severity. This suicide risk domain (scale) enables clinicians to adopt a standard research based “suicide theory” in their suicide risk assessments.
Acute suicide risk calls for prompt intervention or treatment. Acute symptoms vary in severity and abate as the suicide crisis resolves. Acutely suicidal patients can be safely treated in outpatient problems as long as they do not express any suicidal intent (Rudd, 2006). All suicide states have both acute and chronic elements and the assessor needs to differentiate between the two. This differentiation is done or completed by the Suicide Risk Assessment.
Chronic suicide risk is identified by multiple (2+) suicide attempts. Multiple (2+) attempters are more sensitive to suicidal triggers than ideators (or single attempters). Even when an acute suicide crisis is resolved (or acute symptoms have subsided) the patient’s chronic suicide susceptibility has not. Chronic suicidal features can improve and eventually be resolved – however, this only happens after long term care (Rudd, 2006). Acknowledging chronic suicidal features means the patient’s suicide “foreseeability” is “continued in heightened suicide risk. Suicide risk assessment should differentiate between acute and chronic suicide. Chronically suicidal patients can be affectively treated in outpatient programs as long as the patient does not express any suicidal intentions (Rudd, 2006).
There are many terms that address the notion of truthfulness within the context of assessment, treatment and rehabilitation, including: Denial, problem minimization, misrepresentation and equivocation. The prevalence of denial among patients and offenders is extensively discussed in the psychological literature (Marshall, Thornton, Marshall, Fernandez, & Mann, 2001; Brake & Shannon, 1997; Barbaree, 1991; Schlank & Shaw, 1996). The impact the Truthfulness Scale score has on other scale or test scores is contingent upon the severity of denial or untruthfulness. In assessment, socially-desirable responding impacts assessment results when respondents attempt to portray themselves in an overly favorable light (Blanchett, Robinson, Alksnis & Sarin, 1997).
Truthfulness Scale awareness increased with the release of the Minnesota Multiphasic Personality Inventory (MMPI) many years ago. Soon thereafter, socially-desirable responding was demonstrated to impact assessment results (Stoeber, 2001; McBurney, 1994; Alexander, Somerfield & Ensminger, 1993; Paulhus, 1991). Truthfulness Scale conceptualization began in earnest with the idea of self-response accuracy. Test users want to be sure that respondents’ self-report answers were truthful. Evaluators and assessors need to know if they can rely upon the test data being accurate. In other words, can the respondent’s self-report answers be trusted? Research also shows that truthfulness is a factor in diagnosis, treatment effectiveness and recidivism with all patients.
Client (patient or offender) truthfulness has been associated with more positive treatment outcomes (Barber, et. al., 2001). Denial often accompanied lack of accountability, lack of motivation to change, resistance and general uncooperativeness (Simpson 2004). Problem minimization has also been linked to lack of treatment progress (Murphy & Baxter, 1997); treatment dropout (Daly & Peloski, 2000; Evans, Libo & Hser, 2009); and offender recidivism (Nunes, Hanson, Firestone, Moulden, Greenberg & Bradford, 2007; Kropp, Hart, Webster & Eaves, 1995; Grann & Wedin, 2002). Some researchers have suggested that client denial should be eliminated prior to commencing treatment. Denial reduction methods include use of survivor reports, directed group work, or addressing cognitive distortions that may cause denial (Schneider & Wright, 2004).
As multidimensional as denial is (Barrett, Sykes, & Byrnes, 1986; Brake & Shannon, 1997; Happel & Auffrey, 1995; Laflen & Sturm, 1994; Langevin, 1988; Orlando, 1998; Salter, 1988; Trepper & Barrett, 1989), truthfulness is equally multifaceted. Yet, client truthfulness (and denial) are integral to accurate assessment, testing and evaluation. Consequently, truthfulness will continue to be studied in the future.
Client truthfulness is an important area of inquiry in the Suicide Risk Assessment (SRA). Consequently it has domain status. The SRA Truthfulness Scale determines whether or not the patient being assessed was truthful while completing the SRA. The assessor can then decide if he/she can rely upon the patient’s SRA answers. When the SRA Truthfulness Scale is valid (accurate), assessors and treatment staff can trust the patient’s answers and use this information to enhance a patient’s level of care. Accurate (truthful) information provides a sound basis for treatment recommendations.
Depression is described as a dejected or self-depreciating emotional state that varies from normal to pathological proportions. General symptoms such as melancholy and dysphoric mood are included in this definition, as are impaired social-vocational functioning and loss of interest in usual activities. In addition, thoughts of suicide and other cognitive, as well as somatic correlates of depression are included in the Depression Scale.
The Depression Scale reflects common symptoms and concerns. It provides a quantitative score that varies directly with patient’s self-reported symptoms and concerns.
Depression is one of the most commonly occurring mental health disorders. Signs of depression include chronic sadness, loss of interest and pleasure in daily activities (social, occupational, recreational, etc.), depressed mood and feeling worthless. The Suicide Risk Assessment (SRA) Depression Scale identifies depression and quantifies symptom severity.
The higher the Depression Scale score, the more severe the depression. Elevated Depression Scale scores identify early, to middle stages of depression. The higher the score, the more severe the depression. The Depression Scale score can be interpreted independently as a self-report or in terms of its interaction with other SRA scale scores.
Two symptom clusters - anxiety and depression -- are clinically significant and are often co-occurring disorders. They (anxiety and depression) are the most commonly reported symptoms of distress in clinical settings. The interaction or blending of these symptoms is evident in the definition of dysphoria, i.e., a generalized feeling of anxiety, restlessness and depression. Perceived distress represents the major reason people seek help. Anxiety and depression are not mutually exclusive as any given case may represent both symptom clusters. For these reasons separate scales are included in the SRA for anxiety and depression.
With regard to depression the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) a Major Depression Episode diagnosis mandates at least one of the patient’s endorsed symptoms is either a “depressed mood” or “the loss of interest or pleasure in nearly all of the patient’s activities.” In a depression, the patient should experience at least four additional symptoms from the following list of nine symptoms of depression.
A “severe depression” is comparable to a clinical depression, which on its own merits warrants treatment. Severe depression has been linked to suicide attempts. Co-occurring anxiety and/or substance (alcohol/drug) use is a malignant sign and further heightens suicide risk.
A very chronic form of depression is “persistent depressive disorder” which is diagnosed when the mood disturbance (depression) continues for at least two years in adults. This diagnosis is new in DSM-5. People, with depression, are at heightened risk of suicide. Alcohol, drug abuse and Substance Use Disorders have also been linked to suicide in the research literature.
Anxiety is characterized by nervousness, apprehension and somatic correlates of anxiety. Raymond Corsini (1999, Dictionary of Psychology) defined anxiety as “a pervasive and unpleasant feeling of tension, dread, apprehension and impending disaster.” A common definition of anxiety is “excessive worry about everyday real life problems.” Worries are excessive, pervasive and pronounced. They can become focal sources of concern and interfere with relationships, social functioning, occupational performance and other activities.
The higher the Anxiety Scale score is the more severe the problem. Severe Anxiety Scale scores are indicative of intense, pervasive and pronounced apprehension and worries that can disrupt ongoing life activities. At these times acute feelings of tension, stress and apprehension along with anxious expectations permeate the patient’s life.
Other problems and disorders have been linked to anxiety. These include but are not limited to other Suicide Risk Assessment (SRA) scales, or more specifically, the problems and disorders they represent. There is also an Adjustment Disorder with anxiety or with anxiety and depressed mood. Anxiety is inherent in many DSM-5 mental health disorders. Some maintain that any kind of discomfort or illness can foster anxiety.
Anxiety disorders involve excessive or inappropriate states of arousal characterized by feelings of apprehension, uncertainty or fear (A.D.A.M, 2012, nytimes.com). Up to 75 percent of people with other mental illnesses that attempted suicide were also diagnosed with one or more anxiety disorders (Nichols, M., 2008). Nepon, Belik, Bolton & Sareen (2010) concluded clinicians need to assess suicide risk among patients having anxiety problems. Bolton, Cox, Afifi, Enns, Bienvenu & Sareen (2008) support the view that anxiety disorders are important risk factors for suicide attempts.
DSM-5 defines anxiety as excessive worry (apprehensive expectations) about a number of events or activities. The intensity, duration and frequency of the anxiety is out of proportion to the actual likelihood of the anticipated event. DSM-5 anxiety symptom categories include six (6) symptoms. The patient needs to select (endorse) three (3) or more of the following six symptoms:
Some mental health professionals maintain a synonym for anxiety is “stress.” Stress is a known contributor to DSM-5 disorders like depression, anxiety substance (alcohol/drug) abuse, hopelessness, etc. Co-occurring disorders can heighten suicide risk. In summary, anxiety can be an important risk factor in suicide risk.
The Suicide Risk Assessment (SRA) Drug Scale measures prescription and non-prescription drug use and, as appropriate, the severity of abuse. An elevated (Problem Risk range) Drug Scale Score identifies early stage or emerging drug problems. An SRA Drug Scale score in the Severe Problem range identifies established and severe drug abuse. Elevated (Problem Risk range) co-occurring symptoms clusters (disorders) like alcohol, anxiety, substance (alcohol/drug) abuse, etc., often interact -- heightening suicide risk. Elevated Drug Scale scores do not occur by chance. Nevertheless, elevated Alcohol Scale and Drug Scale scores are indicative of co-occurring polysubstance abuse and the highest score typically reflects the patient’s substance of choice. Any Drug Scale score in the severe problem range must be taken seriously.
Although most suicides are committed with firearms, reports reflect a significant increase in drug-related (poisoning) deaths, which include intentional overdoses (New York Times, May 2, 2013, Tara Parker-Pope, “Suicide Rates Rise Sharply in U.S.”). Poisoning deaths were up 24 percent during the last 10-year period.” Patients are at heightened suicide risk when the Drug Scale and Suicide Scale are elevated. Any Drug Scale score in the Severe Problem range should be taken seriously. SRA scale scores can be exacerbated when the patient is abusing drugs. The SRA Drug Scale can be interpreted independently or in combination with other SRA scale scores.
The Suicide Risk Assessment (SRA) Alcohol Scale measures alcohol (beer, wine or liquor) use and the severity of abuse. A recently published study found that the Alcohol Scale percentile score is a strong predictor of DUI/DWI offender recidivism (Bishop, 2011). An elevated (Problem Risk range) Alcohol Scale score identifies emerging or early stage alcohol problems. An SRA Alcohol Scale score in the Severe Problem range identifies established and severe drinking problems. Elevated co-occurring symptom clusters (disorders) like anxiety, drugs or depression, etc. often interact resulting in heightened suicide risk. Co-occurring polysubstance abuse must always be interpreted carefully. Any Alcohol Scale score in the Severe Problem range must be taken seriously. Elevated Alcohol Scale scores do not occur by chance. The Alcohol Scale can be interpreted independently or in combination with other elevated Suicide Risk Assessment (SRA) scales.
The Stress Management Scale is a measure of the patient's ability to handle or cope with their experienced stress. Severely impaired stress coping abilities are usually indicative of other identifiable emotional and mental health problems. Some people handle stress more effectively than others. Stress Management Scale scores at or above the 90th percentile reflect extremely impaired or lack of stress management skills and are often indicative of identifiable emotional or mental health problems. Patients scoring in the Problem Risk range and higher would benefit from learning more effective coping and stress management strategies. They would benefit from attending “stress management classes.”
The Suicide Risk Assessment (SRA) Stress Management Scale measures the patient’s ability to manage the stress that they are experiencing. It is now known that inability to manage stress exacerbates physical and emotional. More specifically, poorly managed stress (pressure, anxiety, etc) contributes to heightened anxiety, depression and substance (alcohol/drug) use. Thus, an elevated (Problem Risk range) Stress Management Scale score in conjunction with other elevated Suicide Risk Assessment (SRA) scales provides considerable insight into the patient’s situation. When a patient doesn’t manage stress well, other problems are usually exacerbated. Such problem augmentation or magnification applies to all co-occurring (co-morbidity) SRA problems, as represented by their SRA Stress Management Scale scores. As a general rule, the higher the SRA scale score, the more severe the problem.
Stress management coping skills strategies and techniques are learned--they are not taught at home or school. Within the last decade, “stress management classes” have emerged. People with stress management (or coping) deficits can now be referred to stress management classes, where participants learn to identify their stress, reframe it and incorporate constructive techniques and strategies for reducing and positively managing it. However, more serious stress managing deficits are usually treated in conjunction with co-occurring disorders. More specifically, when a Stress Management Scale score is in the Problem Risk range, the patient is often referred to stress management classes. An alternative recommendation involves referring the patient to internet discussions of stress management and/or reference books that present stress management philosophy, techniques and strategies. When a Stress Management Scale score is in the Severe Problem range, it is likely that there are serious co-morbid disorders. In these instances, referral for psychotherapy (counseling) is usually warranted.
Among several effective psychotherapies, cognitive behavioral therapy (CBT) is the most popular (Gardener, Rose, Mason, Tyler & Cushway, 2005). The Stress Management Scale can be dealt with independently or in conjunction with management of issues identified by other elevated SRA scale scores. Low and moderate stress management scorers can benefit from reading about how to use stress management techniques (e.g., deep breathing, regular exercise, proper diet, adequate sleep, yoga, meditation, etc.).
Particularly unstable and perilous situations involve an elevated (or severe) Stress Management Scale score with a Problem Risk (or severe) Depression Scale, Anxiety Scale, Alcohol Scale or Drug Scale score. How well a person manages stress affects their overall adjustment.
The Stress Management Scale correlates significantly (.001 level of significance) in predicted directions with the following Minnesota Multiphasic Personality Inventory (MMPI) scales: Psychopathic Deviate (Pd), Psychasthenia (Pt), Anxiety (A), Manifest Anxiety (MAS), Social Responsibility (RE), Social Alienation (PD 4A), Social Maladjustment (SOC), Authority Conflict (AUT), Manifest Hostility (HOS), Suspiciousness/Mistrust (TSC-III), Resentment/Aggression (TSC-V), and Tension/Worry (TSC-VII). Stress exacerbates other symptoms of emotional problems. A Severe Problem Risk range Stress Management Scale score is indicative of markedly impaired stress management (coping) abilities. It also suggests that identifiable emotional and mental health problems are present .
Some forms of psychotherapy address stressful life experiences by teaching social skills that enhance social support and problem-solving skills. Stress is inevitable, consequently learning stress reduction strategies and techniques are important in patient’s mental health. Stress management deficits can be overcome. Yet, stress management deficits can be especially dangerous when combined with co-morbid disorders like depression, anxiety or substance (alcohol/drug) abuse.
The Substance (alcohol/drug) Use Disorder is characterized by the patient continuing to use a substance (alcohol/drug) despite significant substance-related problems. The DSM-5 substance (alcohol/drug) use criterion consists of eleven symptoms, which are paraphrased as follow.
The Suicide Risk Assessment (SRA) Substance Use Disorder is based upon DSM-5 classification criteria. The severity of a patient’s disorder is determined by how many of the eleven (11) Substance Use Disorder symptoms they endorse.
There are important differences between the DSM-5 Substance Use Disorder and the SRA regarding assessment of substance use. The DSM-5 Substance Use Disorder scale incorporates assessment of both alcohol and drug use together, making no distinction between the two. In contrast, in the SRA assessment, the Alcohol Scale focuses exclusively on alcohol (beer, wine or liquor) use and the Drug Scale focuses solely on drug (prescription and nonprescription) use. This difference is far-reaching. Unlike the DSM-5 Substance Use Disorder assessment, the SRA yields specific information about the patient's alcohol and/or drug use, clearly identifying the problem and its magnitude, enabling the matching of the problem and its severity with appropriate treatment at appropriate levels.
Assessment differences between the DSM-5 Substance Use Disorder and the SRA involves time referents. While the DSM-5 uses longer term and even lifetime referents, the Alcohol and Drug Scales of the SRA use short term referents (the here-and-now or recent past), thereby assessing present day risk. Once identified, problematic alcohol or drug risk must be resolved if the patient is to achieve reduced suicide risk in the future.
Another DSM-5 and SRA comparison involves the types of measures used. "Dimensional" measures use recent time frames (e.g., in the past year, in the last month, or now) to measure severity of alcohol and/or drug use. The SRA Alcohol and Drug Scales are both dimensional. In contrast, the substance use measures of the DSM-5 are "categorical," gathering long-term or lifetime occurrence information.
These differences help in understanding seemingly different results. For example, you might have a SRA Alcohol and/or Drug Scale score in one severity range (e.g., low risk) and a DSM-5 Substance Use Disorder classification range in another severity range (e.g., problem risk). Although use of both dimensional and categorical measures in the same test have been advocated (Kessler, 2002, 2008), different types of measures can exacerbate score differences. In summary, factors that can contribute to DSM-5 and SRA Alcohol Scale and Drug Scale scoring differences include: DSM-5’s Substance Use Disorder Scale includes or incorporates both alcohol and drugs in the same scale; whereas, the SRA independently assesses alcohol and drugs in separate scales. Additionally, the DSM-5’s use of categorical measures can lead to results that conflict with the dimensional measures for alcohol and drugs in the SRA.
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