A guide to suicide screening for non-clinician staff provides information about: - Understanding suicide myths and facts as well as prevalence data - Risk and protective factors for suicide - Using the Columbia Suicide Severity Rating Scale (C-SSRS) to screen for suicide risk by asking questions about ideation and behavior - Taking appropriate actions based on the screening such as signposting to support services for low risk, contacting emergency services for very high risk, or contacting mental health services for high risk

1. A guide to suicide
screening for non-
clinician staff on
campus

2. Dave Wilson
Psychological Wellbeing
Manager
University of Cumbria

3. Keeping you safe
• Discussing suicide can evoke painful memories for those who have
lost someone close to them through suicide, or if you have
experienced suicidal ideation or attempts
• If you get distressed by the content of this presentation, or
discussions that take place within it, please do take some time out
from the session
• Speak to me afterwards if you want to refocus your thoughts
• Additionally the University of Cumbria has an Employee Assistance
Programme which includes counselling. Details can be found on
staffnet

4. Outline of the session
• Understand fact from fiction
• Prevalence of suicide
• Risk factors associated with suicide
• Stress vulnerability model
• Difference between suicide screening, risk assessment, risk
management
• The traumatising language of risk in mental health
• Sympathy v’s Empathy
• CSSRS screening tool
• What is it?
• How do you use it?
• Examples

5. Suicide Myths and Facts
• Suicide can’t be prevented
• People who take their own life
are selfish
• Asking someone if they are
feeling suicidal will encourage
them to take their own life
• Preventing this attempt won’t
solve anything
• Suicide is preventable
• People often think they are
acting selflessly
• Reaching out can demonstrate
compassion and show people
that you care
• It can provide time to change
their mind and access support
they hadn’t considered

6. Suicide Myths and Facts
• People who talk about suicide
aren’t serious
• Most suicides occur during the
Christmas holiday period.
• Often people who do go onto
complete suicide have told
someone beforehand
• Suicides tend to peak in late
Spring and early Summer

7. Prevalence
• The World Health Organisation (WHO, 2014) state that globally, a suicide
takes place every 40 seconds. It is the 15th most common cause of death
worldwide
• Surveys carried out in the USA, state that 16.5% of students have thought
about ending their own life (Drum et al, 2009).
• In the USA, suicide is the 2nd leading cause of death for students (after
accidents). Suicide kills more students than all other medical illnesses
combined (National Data on Campus Suicide, 2015)
• 49.5% of students reported feeling hopeless in the past year in the USA
• Two thirds of students struggling with symptoms of depression do not seek
support (American College Health Association, 2015)

8. Prevalence
• In one NUS study (Kerr, 2013) stated that 13% of students surveyed had
suicidal thoughts during their studies, this figure increased to 33%* in 2015
(Gil, 2015)
• In 2014-15 just under half of students who referred to the University of
Cumbria’s Psychological Wellbeing Service indicated some self-harm or
suicidal ideation*

9. What are the risk factors associated with suicide?
• Isolation or loneliness
• Relationship breaking down
• Being bullied
• Bereavement (especially in suicide)
• Problems at work/studies
• Substance misuse (alcohol, drugs)
• Adjusting to big change (such as
starting or moving to university)
• History of physical or sexual abuse
• Debt
• Issues around sexual identity
• Long-term physical pain or illness
• Mental health problems
• Hopelessness
• Access to lethal means
• Previous suicide attempt
• Loss of social network
• Failure in academic studies
• Unable or unwilling to seek support

10. What are the protective factors associated with
suicide?
• Supportive social and family
network
• Problem solving skills
• Conflict resolution skills
• Ability to regulate emotions
• Ability to cope
• Has a positive outlook on life
• Cultural or religious beliefs that
discourage suicide
• Access to mental health care

11. “I jumped off the Golden Gate Bridge”

12. What do we mean by stress?
Episodic Stress
• Bereavement
• Legal problems
• Going to university
• Getting married
• Getting divorced
• Moving house
Ambient Stress
• Housing problems
• Financial problems
• Relationship difficulties
• Social isolation
• Work related stress
• Unemployment
When perceived demand is greater than perceived ability to meet that demand!

13. Stress Vulnerability Model
“Breaking point”
STRESS
VULNERABILITY
Large amount of stress before reaching “breaking point”
Only a small amount of stress needed to reach “breaking point”

14. Stress Vulnerability Model
“Breaking point”
STRESS
VULNERABILITY
Reduce
stress
Reduce vulnerabilityZubin & Spring, 1977

15. The stress bucket – Brabban & Turkington, 2002
We all need
a tap to
release the
pressure

16. Suicide is Preventable
• Identifying someone who is thinking about suicide, and then
directing them to appropriate resources is suicide prevention
• In the USA 79% of college students who die by suicide never
received any campus based services (Gunn & Denino, 2015)

17. Best Practices in Suicide Prevention
• Education about depression and suicide
• This needs to be ongoing and not a one off event
• Early Intervention
• Better outcomes are more likely, the earlier the intervention is
delivered
• Community of caring
• All members of the university community should see suicide
prevention as part of their job
• Referrals to appropriate services
• All faculty and professional service staff should know when and
how to refer
• Prevention of suicides in public places
• Reducing access to means of suicide can disrupt or delay a
suicidal act

18. Suicide Screening, Risk Assessment &
Management
• Suicide Screening is not a full risk assessment
• Risk Assessment is more detailed and good practise dictates that it
should be undertaken by a mental health clinician in collaboration
with the service user
• Both of the above require a Structured Clinical Approach if
following best practise
• Risk management refers to the intervention required to keep a
person safe and functioning, helping them to move on from the
crisis they find themselves in

19. Hierarchy of suicide assessment
Thoughts
of death
Suicidal
ideation
Plan for
suicide
Means
available
Intent
McDowell, et al. 2011

20. The traumatising language of risk in mental
health
“The continuing focus on risk, well-intentioned as it is in reducing harm and
increasing people’s safety, has a stigmatising, and, in some cases, traumatic
effect on people using mental health services. It reinforces the myth that
people who are mentally unwell are an inevitable risk to society, and that
through risk assessment we can minimise or even eliminate this threat. It is
the often unquestioned acceptance of the effectiveness of risk assessment,
and the unconscious bias that emerges from this narrative that poses the
biggest risk.”
“Moving forwards, risk assessment needs to be focussed on safety issues –
secured by a desire to improve, reintegrate, retrain, and foster recovery.”
“By placing ‘safety’ at the heart of our work around risk; acting with both
compassion and clinical-knowledge, we can ensure better outcomes for all
involved.”
http://blog.oup.com/2016/01/risk-mental-health-nursing/
Prof. P. Callaghan, 2016

21. International Association for Suicide Prevention
• First contact
• Not everyone has to take on the responsibility of treating those with
suicidal thoughts and actions, but at the very least those who are in the
situation where such persons may present should have the basic skills
to make a general assessment of suicidal persons. The initial contact is
particularly important, as often a suicidal person has recently perceived
rejection, so building up some rapport and the use of empathy is key.
• Degree of suicidal intent
• Suicidal intent can be determined on the basis of the degree of
planning, knowledge of lethality, the degree of isolation etc., especially
by asking open ended questions which can illicit some ambivalent
feelings
• Initial management
• The most important initial decision is based on one’s assessment of the
safety of the suicidal person. It may be that the opportunity to discuss
thoughts and feelings is sufficient for the person. Or it may be
signposting to specialist services that are required

22. Empathy v’s Sympathy

23. Columbia Suicide Severity Rating Scale (CSSRS)
Who uses it?
• US Military
• Some US law enforcement departments
• Some US fire departments
• US schools, colleges and universities
• First Aiders
• Homeless shelters
• Bus and Taxi drivers in San Francisco
• University of Cumbria Psychological Wellbeing Service
Posner, K. et al

24. Structured Clinical Approach v’s Tick-box
Approach

25. Columbia Suicide Severity Rating Scale (CSSRS)
• Developed by leading experts on suicide attempters
• Evidence based
• Short administration time
• Can be administered by non-mental health clinicians
• Used internationally across research, clinical and institutional
settings
• More accurate than relying on PHQ-9 Q9
• It’s a checklist, not a tickbox exercise
Posner, K. et al

26. CSSRS Screener Items
1. Wish to be Dead
• Have you wished you were dead or wished you could go
to sleep and not wake up?
2. Non-specific Active Suicidal Thoughts
• Have you actually had any thoughts of killing yourself?
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent
to Act
• Have you been thinking about how you might do this?

27. CSSRS Screener Items
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent
to Act
• Have you been thinking about how you might do this?
4. Active Suicidal Ideation with Some Intent to Act, without Specific
Plan
• Have you had these thoughts and had some intention of
acting on them?

28. CSSRS Screener Items
5. Active Suicidal Ideation with Specific Plan and Intent
• Have you started to work out or worked out the details of
how to kill yourself? Do you intend to carry out this plan?
6. Suicide Behaviour
• Have you ever done anything, started to do anything, or
prepared anything to end your life?
• (If “YES”) How long ago did you do any of these?

29. CSSRS Screener Training Video

30. Case study - Georgia
Beth comes to your office at 9.00am to state that Georgia last night had spoken to her about
feeling suicidal. Beth stated that Georgia has spoken a couple of times before about feeling
depressed, but never mentioned suicide. Beth states that she stayed up all night, whilst Georgia
feel asleep on Beth’s bed.
You ask Georgia to come to your office. She walks in looking tired, and very pale. You give a brief
introduction as to why you have invited her down to your office. She is tearful, and states she
needs help. You explain that you want to help, and that you have a few questions to ask.
You: “Have you wished you were dead or wished you could go to sleep and not wake up?”
Georgia: “Yes, it feels like such a long time that I have been feeling this way.”
You: “Have you actually had any thoughts of killing yourself?”
Georgia: “No, not really, I am just fed up… I’m crying all the time”
You: “Have you ever done anything, started to do anything, or prepared to end your life?”
Georgia: “No, not at all! I think I was so upset last night. I got a grade I wasn’t happy with, and it
was the final straw on the donkey’s back. Beth just happened to be around when my thoughts
spewed out of my mouth. I didn’t mean any of the things I said”
You: “It sounds like you are going through a really tough time. Did you know that students can
get support to overcome the kinds of problems you are going through at the moment? You
could try…”

31. Case study - Rosemary
Rosemary sends an email. In it she explains that she, “…can’t cope with the pressure, and can’t
get the dark thoughts out of her head.”
You phone Rosemary.
You: Hi Rosemary, I got your email and I was worried about you. I am phoning to see if there is
anything I can do to help.
Rosemary: I can’t get the thoughts out of my head. I keep thinking about death.
You: “Have you wished you were dead or wished you could go to sleep and not wake up?”
Rosemary: “Yes!”
You: “Have you actually had any thoughts of killing yourself?”
Rosemary: “Yes” (she starts to cry).
You: “ That’s a dark place to be isn’t it? Have you ever done anything, started to do anything,
or prepared to end your life?”
Rosemary: “I once found myself staring at a big box of paracetamol and thought about taking
the whole lot”
You: “When you get thoughts like that, it can be hard to shake them. Have you ever had these
thoughts and had some intention of acting on them?”
Rosemary: “No, never. It was just thoughts… that was all.”

32. Case study - Hans
One of the Residential Coordinators comes to you in a panic stating that Hans has Tweeted a
message saying:
“goodbye I am sorry for hurting any of you by what I am about to do! #LightsGoingOut”
You go with the RC to Hans room and knock on his door. He looks startled when he answers. You
explain that you have seen the Tweet and that you would like to speak to him about it.
You: “Have you wished you were dead or wished you could go to sleep and not wake up?”
Hans: “It’s that obvious? Yeah, I can’t take it anymore I have been thinking about death… about
killing myself for weeks. And for days I have been thinking about an overdose or drowning or
both. I just can’t get the thoughts out of my head. There really isn’t any point in living right now.
It’s not like my mum cares, and I haven’t seen my dad in 5 years. But now my gran has died,
what’s the point in living? …I walked to the bridge last night and stared into the dark black
water, and that is how my life felt, it felt shit! …It is shit! It will always be shit!”
• What C-SSRS questions has Hans already answered?
• What additional questions still need to be asked?

33. 1st role play
Everyone’s favourite activity!

34. Actions to take
Recent
Suicidal
Ideation
Past
Suicidal
Ideation
Recent
Suicidal
Behaviour
Past
Suicidal
Behaviour
Action Required
Very low
risk
0 0 0 0 Little or none
Low risk 1-2 1-3 0 0 Signpost to PWS
Moderate
risk
3 4-5 0 Y Signpost to PWS or
GP
High risk 4-5 4-5 0 Y NHS Mental Health
Support
Very high
risk
4-5 4-5 Y Y Emergency Action

35. Very low to low risk
• Very low risk - Typically you may wish to signpost the student to
speak to family, friends, personal tutor, chaplaincy, Students’
Union, Residential Coordinators, etc. But state if there is a change
for the worse, to consider the Psychological Wellbeing Service
• Low risk – Encourage the student to refer to the Psychological
Wellbeing Service (PWS). The PWS would assess the situation in
more detail. PWS would likely offer short-term solution focussed
therapy, with or without the use of some self-help materials.

36. Medium risk
• Encourage the student to access the Psychological Wellbeing
Service
• Encourage the student to see their G.P.
• Encourage them to refer to First Step in Cumbria, Mindsmatter in
Lancashire, Tower Hamlets Primary Care Psychology Service, EIDR
• Samaritans have a national number 116 123. They have local
branches you can visit
• 1-5 Angus St, London
• 16 Hartington St, Barrow
• 21 Sun Street Lancaster
• 119-123 Botchergate, Carlisle

37. High risk
• If the student is known to adult mental health services, ask the
student if you can contact the student’s care coordinator to get
some crisis support.
• Crisis Resolution & Home Treatment Team for your area (usually by
a single point of access for all of adult mental health services)
• Cumbria campuses should ring: the student’s GP first for an emergency
appointment
• Lancaster campus should ring: SPoA 01524 550504
• London: Tower Hamlets 020 8121 5499 Crisis & Emergency, Liaison and Home Treatment
Team
• Or 111 to speak to someone on the NHS helpline

38. Very high risk
• Will require a 999 call
• Paramedic will assess
• Police have specific duty under the MHA to take a person to a
place of safety
• You will likely need support from a colleague
• If available one of the Psychological Wellbeing Service staff can
assist – but note all but the manager are part-time

39. High or Very high risk - Postvention
• Use the Incident Reporting mechanism so that key people within
the University are made aware of the situation and can monitor the
situation
• Do give yourself time to reflect on the situation. Speak to your line
manager to gain support! But don’t gossip – remember
compassion, dignity and empathy!
• Consider contacting the Employee Assistance Programme (EAP) if
you are deeply affected
• If you haven’t already done so, contact the Psychological Wellbeing
Service Manager (Dave Wilson) or the Head of Learning Services
(Honor Rhodes – who also has lead safeguarding responsibilities)

40. 2nd role play
You’ll all deserve an Oscar™ by the end of today!

41. Last points!
• Just want to thank you all for attending
• It’s not an easy subject to listen to and discuss, but it might save
someone’s life!
• Please remember the support available to you – it can be
emotionally draining discussing suicide, and you need to look after
Number 1!

42. The beginning