Executive functioning as a component of suicide risk assessment: clarifying its role in standard clinical applications.

Clinically, because executive dysfunction (e.g., impulsivity,, insight, thinking process) is often thought of in the context of those with traumatic brain injuries and other neurologic conditions, its formal assessment has historically been seen as the domain of those who assess and treat patients with neurologic disease. However, mental health counselors (MHCs) could benefit from learning how executive functioning relates to suicide risk assessment and coping strategies. Assessment of executive functions can be incorporated in routine clinical practice without the need for formal neuropsychological measures or other time-consuming procedures. In fact, during standard clinical assessment, mental health professionals often informally assess components of executive functioning such as impulsivity, insight, and thinking processes. This article highlights aspects of executive functioning with which MHCs may already be familiar and demonstrates their clinical utility in enhancing assessment and management of suicide-related thoughts and behaviors.

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Although executive dysfunction is often thought of in the context of such neurologic conditions as traumatic brain injury, mental health counselors (MHCs) could benefit from knowing how executive functioning relates to suicide risk assessment and coping strategies. Executive functioning refers to a set of higher-order mental activities primarily governed by' the frontal lobes (Lezak, Howieson, & Loring, 2004; McDonald, Flashman, & Saykin, 2002) including initiation, planning, and self-regulation of goal-directed behavior (Berger & Posner, 2000; Lezak et al., 2004). During standard clinical assessment mental health professionals often assess such components of executive functioning as impulsivity and insight. Also evaluated, though less often, are thinking processes (e.g., concrete versus flexible).

It is well established that deficits in executive functioning can lead to significant disruptions in everyday functioning, even when other cognitive functions are relatively intact (Bechara, Damasio, & Damasio, 2000). Identification of impaired executive functions and their real world implications (e.g., increased risk for suicidal behavior) are therefore receiving increased research attention (Dougherty et al., 2004; Jollant et al., 2005; Keilp et al., 2001). For example, one study of within-group differences in individuals with a history of at least one suicide attempt found that responses to a laboratory-based measure of impulsivity increased with the number of suicide attempts (i.e., those with the highest number of past suicide attempts responded more impulsively; Dougherty et al., 2004). Studies have also found between-group differences: In an investigation of executive functioning in individuals with a history of suicide attempts, those with affective disorders, and healthy comparison subjects, researchers found that on a decision-making task those who had attempted suicide demonstrated more executive dysfunction (Jollant et al., 2005). Another study found differences between high-lethality suicide attempters and three other groups (low-lethality attempters, depressed subjects, and non-depressed control subjects) with regard to inability to employ a previously successful strategy on a neuropsychological task (Keilp et al., 2001).

Traditional means of suicide risk assessment have often focused on the identification of risk and protective factors. Risk factors are any factors empirically associated with suicide (Rudd et al., 2006). A variety of risk factors identified in the suicide literature are summarized in Table 1. Although knowledge of such factors provides general information about potential sources of increased risk (Brenner & Homaifar, 2009), many (e.g., history of impulsivity, history of substance abuse) are not specific to suicide and have limited utility in predicting behavior. Identifying long-standing risk factors (e.g., age, gender) alone is thus not sufficient in assessing suicide risk; the current emotional, cognitive, and behavioral state of the individual must be considered.

Consequently, the focus has recently turned to suicide warning signs (Rudd, et al., 2006). Compared to the distal nature of suicide risk factors, warning signs are precipitating emotions, thoughts, or behaviors (e.g., impulsively drinking after an argument with a family member) that are inherently proximal to suicidal behavior and reflect imminent risk (see Table 2). The ability to identify warning signs and other unique circumstances that may trigger a suicide-related crisis requires individuals to have insight into their own functioning. Furthermore, once a crisis has been identified, coping with it requires an ability to flexibly employ various strategies, potentially adapting them to the circumstances until one works (e.g., if taking a walk typically distracts someone long enough for the crisis to pass, what happens when it's raining?). Making use of coping strategies involves executive functioning.

Unfortunately, some patients have difficulty not only gaining insight into and then identifying warning signs but also coping with a crisis when the signs are present. A prime example can be found in a qualitative study (Brenner, Homaifar, Wolfman, Kemp, & Adler, 2009) wherein participants with histories of suicidal thoughts/behaviors and traumatic brain injury discussed deficits negatively impacting their ability to track suicide warning signs, employ coping strategies, or see alternatives to intentional self-harm behavior. Suicide was frequently seen as "the only way" (Brenner et al., 2009, p. 393). Therefore, understanding factors that may influence the ability to identify and successfully cope with an emerging suicidal crisis is crucial to suicide prevention. Although MHGs may be assessing risk factors and warning signs as well as helping patients cope with suicide-related crises, they may still feel they do not fully appreciate risk and opportunities to intervene. Here, understanding the impact of executive functioning may be useful.

Certain executive functions may be particularly important in assessing suicide risk. Examples include managing impulsive thoughts, considering the consequences of one's actions before acting, and deriving alternative solutions or strategies to effectively deal with challenges and problems. In clinical practice, formal assessment of executive functioning has historically been seen as the domain of those who assess and treat patients with neurologic disease and may consist of various paper and pencil or computerized tools, such as the Wisconsin Card Sorting Task, which measures such aspects of executive dysfunction as perseveration (Heaton, Chelune, Talley, Kay, & Curtiss, 1993). However, basic assessment of executive functions can be incorporated into routine clinical practice without the need for formal neuropsychological measures or other time-consuming procedures. Based on our experience in suicidology, assessment, and rehabilitation psychology, we have developed some initial steps for assessing executive functioning with a clinical audience in mind. The intention here is to highlight several aspects of executive functioning with which MHGs may already be familiar and demonstrate their clinical utility in enhancing assessment and management of suicide-related thoughts and behaviors.

Several formal suicide risk assessment tools have incorporated executive functioning components such as impulsivity and thinking process. With regard to the former, Rudd (2006) discussed "impaired self-control" (p. 71) in delineating levels of acute suicide risk among those with severe and extreme risk for suicide. In this context, impaired self-control may be related to problems with impulsivity and has implications for suicide risk. Joiner et al. (2007) stated that in some individuals "cognitive constriction" contributes to the feeling of being "trapped" (p. 357), which they believe underlies the desire for suicide. Here, cognitive constriction may be related to a concrete thinking process during which an individual feels that there is no other choice but suicide. Finally, the American Association of Suicidology refers to various warning signs for suicidal behavior (i.e., behaviors that those at acute risk for suicidal behavior often demonstrate, such as "acting reckless" and "feeling trapped"; American Association of Suicidology [n.d.], Additional Warning Signs). Acting recklessly and feeling trapped may represent impulsivity and a concrete thinking process which, when combined, lead to an increased risk for suicide. Despite the attempts of some MHCs to incorporate components of executive functioning into formal suicide risk assessment, limited clinical guidance is available about how to assess these components and subsequently how to incorporate this knowledge into their understanding of an individual's suicide risk.

Notably, one study of suicide risk assessment approaches has shown that MHCs across disciplines eschew the use of formal assessment approaches in favor of using clinical interviews (Jobes, Eyman, & Yufit, 1995). Additionally, there is no current standard of care requirement dictating the use of psychological tests in assessing suicide risk (Simon, 2009). Since formal assessments of executive functioning require more time, training, and resources than most MHCs are able to offer, providers use their own ways of assessing executive functioning, as they do when evaluating mental status. The use of these skills to augment the conceptualization of suicide risk is demonstrated below.

EXECUTIVE FUNCTIONING COMPONENTS, CLINICAL RELEVANCE, EVALUATION, AND INTERVENTION

A brief synthesis of executive functioning components believed to be most salient to suicide risk assessment and safety management (i.e., impulsivity, insight, and thinking processes) will be provided. This synthesis describes each component, highlighting its clinical relevance to suicide risk. Also discussed are issues pertaining to suicide risk and management of safety, with suggestions for evaluation (informal and formal) and intervention strategies.

Impulsivity (Inhibition)

Impulsivity can be thought of as a failure to inhibit or problems with disinhibition. The ability to inhibit a particular behavior requires the ability to modulate behavior and avoid impulsive responding (Lezak et al., 2004). For example, an individual with impaired inhibition may exhibit decreased behavioral control and be more likely to engage in impulsive or risky behavior, while an individual with sufficient inhibition may exert a high amount of control over behaviors and be less likely to engage in risky or impulsive behavior.

Clinical relevance: In order for self-regulation to occur, one must be able to inhibit responses (Barkley, 1997). With respect to suicidal behaviors, the ability to inhibit allows one to modify his or her emotional expression and enables that individual to select more adaptive responses or alternatives to suicide. Research shows that compared to individuals who have not attempted suicide, those with a history of suicidal behavior show deficits in impulse control (Dougherty et al., 2004). For some individuals, suicidal behavior may occur within 10 minutes of having had suicidal ideation (Deisenhammer et al., 2009). Additionally, individuals with a history of impulsive behavior may also be less likely to make use of safety management techniques such as crisis management cards (Jobes, 2006; Rudd, 2006). These cards often contain a list of collaboratively developed resources, tools, or pro-therapeutic activities that essentially provide the patient with coping strategies and remind him or her that there are a variety of ways to manage distress in order to get through a crisis.

Evaluation: In clinical practice MHGs often assess the likelihood of future impulsivity based on past behaviors (e.g., drug abuse, reckless driving, etc.). For a more formal assessment MHGs could use the following questions proposed by Rudd (2006, p. 59):

(1) Do you consider yourself an impulsive person? (2) Why or why not? (3) When have you felt out of control in the past? (4) What did you do that you thought was out of control? (5) What did you do to help yourself feel more in control? (6) When you're feeling out of control, how long does it usually take for you to recover?

If the answers to these questions indicate that a patient has felt out of control or impulsive immediately prior to a suicide-related thought/behavior, then impulsivity may not only be a risk factor but could also be a warning sign.

Intervention: If possible, the first line of intervention should include removing access to lethal means. Where this is not possible, devising barriers to lethal means is encouraged (Rudd, 2006). To manage safety, MHCs could make items on crisis management cards simpler and ensure that the coping strategies have a component of immediate gratification. For example, items could be as simple as listening to music, ensuring that songs chosen are uplifting. Clinicians can also work with patients to increase accessibility to crisis cards by making multiple copies and identifying several locations where they may be stored.

Insight (Lack of Self-Awareness)

Insight is an appreciation of one's own behavior as well as the impact one makes on others (Lezak et al., 2004). With respect to mental illness, poor insight may be characterized by deficits in awareness of having a mental disorder, the specific symptoms of the illness, and the impact or consequences of the illness (Flashman, Amador, & McAllister, 2005).

Clinical relevance: Individuals with impaired insight may not believe they are valuable to others, despite evidence to the contrary. They may also not appreciate the impact that their suicidal behavior would have on others, thus making it difficult for providers to help create or bolster protective factors. Individuals who lack insight into the nature of their mental illness may also be at increased risk for suicidal behavior. Having such insight may offer reassurance about the episodic nature of illness and the ebb and flow of symptoms, which in turn may reduce the feelings of hopelessness that are often associated with suicide (Beck, Steer, Kovacs, & Garrison, 1985; Lincoln, Lullmann, & Rief, 2007). Lack of insight also prevents individuals from realizing how current maladaptive coping strategies (e.g., substance abuse) may contribute to their problems and increase their risk for suicidal behavior. Similarly, poor insight may contribute to noncompliance with treatment because patients who are not aware of the nature of their mental illness and certain triggers for suicidality may be less likely to comply with treatment or employ strategies to ensure their safely during a suicide-related crisis (Lincoln et al., 2007).

Evaluation: General questions on insight often address the following two areas: (a) whether individuals are aware of the interactions between their problems and their behavior; and (b) the extent to which individuals believe they need treatment. With respect to suicidal behavior, it is important for individuals to recognize warning signs that immediately precede a suicidal crisis as this is one of the most effective ways of preventing suicidal behavior (Stanley & Brown, 2008). In helping patients identify these signs, the clinician may ask: "What are some of the thoughts or feelings you experience right before you start to think about suicide?" or "What kinds of experiences make you feel so overwhelmed and distressed that you start to think about suicide?"

Another way of assessing insight is implicit in recommendations set forth by Joiner et al. (2009). Though aimed at measuring the constructs of belongingness and burdensomeness, Joiner et al. (2009) encouraged MHCs to assess "the degree to which clients feel connected to--and cared about--by others" (p. 644), as well as the degree to which clients believe that others would be better off if they were gone. Informal assessment of the degree to which individuals feel like they belong or are a burden to others could be as simple as, "To what extent do you feel like you belong/are a burden to others?" If a patient's answers to these questions indicate that lack of insight underlies feelings of not being connected to and cared about by others, then this may be underlying their suicidal ideation in part. MHCs interested in a more formal assessment of these constructs can use the Interpersonal Needs Questionnaire (Van Orden, Witte, Gordon, Bender, & Joiner, 2008).

Intervention: Involving family and loved ones in treatment, as appropriate, may help bolster clients' sense of feeling connected to others, as well as give them an opportunity to see firsthand how their suicide would affect those around them. Additionally, providing patients with psychoeducation about psychiatric illness may help them gain insight into their mental disorder, improve their perceptions of the illness, and promote expectations of recovery. Patients can use this insight to get through difficult times, as such knowledge may enhance their ability to tolerate exacerbations of symptoms and increase their awareness of times when they may need to seek additional support. For example, helping patients increase awareness of the specific triggers that contribute to a suicidal crisis (e.g., arguing with spouse, feeling lonely, having nightmares) may enable them to better employ certain coping strategies that may then prevent their suicidal ideation from further escalating.

Thinking Process (Concept Formation and Self-Regulation)

This component combines two executive functioning components, which are not necessarily mutually exclusive. Concept formation addresses the process of how one thinks, rather than the content, and resides on a continuum between abstract and concrete; self regulation is the ability to be flexible in the way one thinks about how to solve a problem, shifting behavior when necessary (Lezak et al., 2004).

Clinical relevance: Individuals with concrete, inflexible thinking may have a bevy of maladaptive coping strategies that they continue using to no avail. When acutely suicidal, they may lack the cognitive flexibility needed to identify new solutions or strategies to cope with the issues driving their suicidal thoughts. They often become fixated on suicide (Maris, Berman, & Silverman, 2000) to the extent that their ability to see coping alternatives is significantly restricted (Shneidman & Farberow, 1957). In turn, they can become increasingly hopeless, which places them at greater risk for suicidal behavior. During times of acute distress, they may turn to existing coping strategies, which may have failed them in previous situations, rather than considering a broader range of options. If familiar coping strategies do not reduce their acute distress, they may find it difficult to broaden their thinking to find other ways to stay safe.

Evaluation: Assessing thought process necessitates paying attention to how the individual answers questions throughout the clinical interview. Often MHCs will note when their clients become paralyzed because long-established coping mechanisms do not work in a crisis situation. Other areas to pay particular attention to are responses that indicate any of the following tendencies: (a) noting only superficial features of life experiences (e.g., clients who give step-by-step factual accounts of a painful event, such as a divorce, as opposed to discussing how they were impacted); (b) offering only very specific examples to general questions (e.g., clients who have difficulty reporting what their mood is generally like and instead state what their mood is at that moment); and (c) having an overly broad or narrow degree of generalization (e.g., clients who overgeneralize or demonstrate black and white thinking; Zuckerman, 2000). To assess specifically how flexible patients may be when dealing with a suicidal crisis, the clinician may ask: "What can you do if you become suicidal again to help yourself not to act on your thoughts or urges?" "What activities could you do to help take your mind off your problems even if it is for a brief period of time?" (Stanley & Brown, 2008, pp. 5-6). Inability to derive alternative strategies or flexibly employ coping strategies in a crisis indicates that a patient's impaired thinking process is an important warning sign.

Intervention: Providing patients with a variety of concrete coping strategies to use during times of crisis may be a particularly effective way of helping them to come up with alternative ways to manage extreme emotional distress. For example, if using a crisis management card (Jobes, 2006; Rudd, 2006), once items are listed (e.g., taking a walk), MHCs can trouble-shoot with patients regarding scenarios in which the patient may not be able to engage in the pro-therapeutic activities (e.g., what if it is raining outside?).

Table 3 lists quick, informal ways to assess these components, things to listen for when conceptualizing suicide risk, and brief examples of interventions. MHCs are encouraged to refer to the body of the manuscript for a more thorough description of each component.

CONCLUSION

Given that executive dysfunction often occurs in multiple areas (e.g., impulsivity, insight, and self-regulation; Lezak et al., 2004), it is unlikely that MHCs would only identify problems in one of these areas when evaluating a person for suicide risk. Therefore, MHCs need to be prepared to deal with the complexity of having such problems co-occur, necessitating more consideration in managing crises when helping patients mitigate risk. Ultimately it is hoped that because MHCs are likely familiar with some components of executive functioning, applying these components in understanding suicide-related thoughts and behaviors may help to better conceptualize and mitigate suicide risk. As with other risk factors and warning signs, however, the presence of executive dysfunction does not necessarily indicate suicide risk and only considering executive functioning would be insufficient. Assessing suicide risk should be considered an ongoing process rather than an event (Simon, 2009), and MHCs are encouraged to use their clinical judgment in doing so.

Executive dysfunction under certain circumstances may facilitate suicidal behavior in some individuals and not in others. However, it is not yet known why, when, and under what conditions executive dysfunction may place an individual at higher risk for suicide. There are currently no published empirical studies on coping strategies as they relate to executive functioning and suicide risk assessment. To begin building the knowledge base in this area, future research should make use of ecologically valid measures of executive functioning to determine what, if any, relationships exist with regard to coping with suicide-related crises. It is hoped that research in this area will help MHCs conduct more focused and nuanced interventions for those at risk for suicide.

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Deisenhammer, E. A., Ing, C. M., Strauss, R., Kemmler, G., Hinterhuber, H., & Weiss, E. M. (2009). The duration of the suicidal process: How much time is left for intervention between consideration and accomplishment of a suicide attempt? Journal of Clinical Psychiatry, 70, 19-24.

Dougherty, D. M., Mathias, C. W., Marsh, D. M., Papageorgiou, T. D., Swann, A. C., & Moeller, F. G. (2004). Laboratory measured behavioral impulsivity relates to suicide attempt history. Suicide and Life-Threatening Behavior, 34, 374-385. doi:10.1521/suli.34.4.374.53738

Flashman, L. A., Amador, X., & McAllister, T. W. (2005). Awareness of deficits. In J. M. Silver, T. W. McAllister, & S. C. Yudofsky (Eds.), Textbook of traumatic brain injury (pp. 353-368). Washington, DC: American Psychiatric Publishing, Inc.

Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (1993). Wisconsin Card Sorting Test manual: Revised and expanded. Odessa, FL: Psychological Assessment Resources, Inc.

Jobes, D. A., (2006). Managing suicidal risk: A collaborative approach. New York, NY: The Guildford Press.

Jobes, D. A., Eyman, J. R., & Yufit, R. I. (1995). How MHCs assess suicide risk in adolescents and adults. Crisis Intervention and Time-Limited Treatment, 2, 1-12.

Joiner, T. E. Jr., Kalafat, J., Draper, J., Stokes, H., Knudson, M., Berman, A. L., & McKeon, R. (2007). Establishing standards for the assessment of suicide risk among callers to the National Suicide Prevention Lifeline. Suicide and Life-Threatening Behavior, 37, 353-365.

Joiner, T. E., Jr., Van Orden, K. A., Witte, T. K., Selby, E. A., Riberio, J. D., Lewis, R., & Rudd, M. D. (2009). Main predictions of the interpersonal-psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of Abnormal Psychology, 118, 634-646.

Jollant, E, Bellivier, F., Leboyer, M., Astruc, B., Torres, S., Verdier, R.... Courtet, P. (2005). Impaired decision making in suicide attempters. American Journal of Psychiatry, 162, 304-310. doi:162/2/304 [pii] 10.1176/appi.ajp.162.2.304

Keilp, J. G., Sackeim, H. A., Brodsky, B. S., Oquendo, M. A., Malone, K. M., & Mann, J. J. (2001). Neuropsychological dysfunction in depressed suicide attempters. American Journal of Psychiatry, 158, 735-741.

Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychological assessment (4th ed.). New York, NY: Oxford University Press.

Lincoln, T. M., Lullmann, E., & Rief, W. (2007). Correlates and long-term consequences of poor insight in patients with schizophrenia: A systematic review. Schizophrenia Bulletin, 33, 1324-1342.

Maris, R. W., Berman, A., & Silverman, M. M. (Eds.). (2000). Comprehensive textbook of suicidology. New York, NY: Guilford Press.

McDonald, B. C., Flashman, L. A., & Saykin, A. J. (2002). Executive dysfunction following traumatic brain injury: Neural substrates and treatment strategies. NeuroRehabilitation, 17, 333-344.

Rudd, M. D. (2006). The assessment and management of suicidality. Sarasota, FL: Professional Resource Press.

Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., ... Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36, 255-262. doi:10.1521/suli.2006.36.3.255

Shneidman, E. S., & Farberow, N. L. (Eds.). (1957). Clues to suicide. New York, NY: McGraw-Hill.

Simon, R. I. (2009). Suicide risk assessment forms: Form over substance? Journal of the American Academy of Psychiatry and the Law, 37, 290-293.

Stanley, B., & Brown, G. K. (with Karlin, B., Kemp, J., & Von Bergen, H.). (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Washington, DC: United States Department of Veterans Affairs.

Van Orden, K A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner, T. E., Jr. (2008). Suicidal desire and the capability for suicide: A test of the interpersonal psychological theory in adults. Journal of Consulting and Clinical Psychology, 76, 72-83.

Zuckerman, E. L. (2000). Clinician's thesaurus (5th ed.). New York, NY: Guilford Press.

At the time of writing all authors were affiliated with the Department of Veterans Affairs, VISN 19 Mental Illness Research, Education and Clinical Center (MIRECC) and with the University of Colorado Denver School of Medicine. Dr. Homaifar is now affiliated with the VA Boston Healthcare System and Boston University. Correspondence concerning this article should be sent to Beeta Homaifar, VISN 19 MIRECC, 1055 Clermont St., Denver, Colorado 80220. E-mail: [e-mail].

Acknowledgment: The authors thank Ron Biela, LCSW, and Naomi Greenstone, LCSW, who reviewed this manuscript and provided helpful comments.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Table 1. Risk Factors for Suicide

Demographic
  Age
  Male gender
  Caucasian

Environmental
  Unemployment
  Financial difficulties
  Negative life events
  Marital/relational problems
  Loss of social support/isolation
  Access to lethal means

Biopsychosocial
  Psychiatric illness
  Substance use disorder
  Anger, aggression
  Impulsivity
  Suicidal ideation
  Prior suicide attempt
  Hopelessness
  Family history of suicide
  Physical illness

Source. Maris, P. W, Berman, A., & Silverman, M. M. (Eds.). (2000).
Comprehensive textbook of suicidology. New York, NY Guilford Press.

Table 2. Warning Signs for Suicide

Threatening to hurt or kill self
Looking for ways to kill self (seeking access to pills, weapons,
 or other means)
Talking or writing about death, dying, or suicide
Hopelessness
Rage, anger, seeking revenge
Acting reckless or engaging in risky activities
Feeling trapped
Increased alcohol or drug use
Withdrawing from friends, family, or society
Anxiety, agitation
Unable to sleep or sleeps all the time
Dramatic changes in mood
No reason for living; no sense of purpose in life

Source. Rudd, M.D., Berman, A.L., Joiner, T.E., Nock, M.K., Silverman,
M.M., Mandrusiak, M.,... Witte, T. (2006). Warning signs for suicide:
Theory, research, and clinical applications. Suicide and
Life-Threatening Behavior, 36, 255-262.

Table 3. Brief Tips for Evaluation and Intervention of Executive
Functioning as it Relates to Suicidal Thoughts and Behaviors

                       Sample
                    Questions to
   Executive          Augment a
  Functioning       Suicide Risk     What to Listen
   Component         Assessment            For          Intervention

Impulsivity        When you're       A coping          Coping
                   feeling out of    strategy that     strategies
                   control, how      would take too    should be
                   long is it        long to reduce    tailored to
                   before you feel   feelings of       produce
                   like you have     being out of      immediate
                   to act on your    control (e.g.,    gratification
                   thoughts?         if it takes 5     (e.g., calling
                                     minutes before    a loved one or
                                     they feel they    playing with a
                                     must act on       pet)
                                     their thoughts,
                                     then coping via
                                     watching a
                                     2-hour movie
                                     may not be the
                                     best choice)

Insight            How much do you   Lack of           Helping
                   think that        awareness of      patients
                   others would be   the impact        identify
                   better off if     their suicide     triggers that
                   you were gone?    would make on     contribute to
                   Does this         others and/or     their problems
                   happen            their value to    with insight
                   regardless of     others            (e.g., an
                   whether you                         argument with a
                   feel like they                      spouse that
                   value you?                          makes them feel
                                                       devalued)

Thinking process   How would you     Degrees of        Once coping
                   cope during a     concreteness,     strategies are
                   suicidal          inflexible        identified,
                   crisis?           thinking          trouble-
                                                       shooting with
                   What if that                        patients (e.g.,
                   doesn't work?                       if visiting a
                                                       friend makes
                                                       things better,
                                                       what happens if
                                                       the friend is
                                                       busy?)