Suicide Evaluation (SE) Scale Description

There are several approaches to Suicide Evaluation (SE) scale interpretation, ranging from viewing the Suicide Evaluation (SE) as a self-report to examining elevated scale scores and relationships between scale scores. As shown in the table below, the four Suicide Evaluation (SE) scale risk ranges are Low Risk, Medium Risk, Problem Risk and Severe Problem.

With any Suicide Evaluation (SE) scale, a problem is not identified unless a scale score is at or above the 70th percentile. Scores at the 70th percentile or higher are referred to as elevated scores. Scores at the 70th to 89th percentile are in the problem range, and scale scores at or above the 90th percentile are in the severe problem range.

Description and discussion of each Suicide Evaluation (SE) scale follows.

Truthfulness Scale: Measures how truthful the individual was while completing the Suicide Evaluation (SE). It identifies guarded and defensive individuals. In terms of suicide risk assessment, it is important to know if the potentially suicidal individual was truthful when tested (Simon, 2002) and if you can rely upon the information provided. Suicidal individuals may attempt to deny or minimize their problems or suicidal ideation. Truthfulness scale scores at or below the 89th percentile mean that all Suicide Evaluation (SE) scales are accurate. Scale scores in the 70 to 89th percentile range are accurate because they have been Truth-Corrected. Truthfulness Scale scores at or above the 90th percentile mean that all SI scales are inaccurate (invalid) because the respondent was overly guarded, was minimizing problems, or was attempting to fake answers. Individuals with reading impairments might also score in the elevated score range. If not consciously deceptive, individuals 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 determines whether or not the respondent answered SE test items honestly. One of the first things to check when reviewing an SE report is the Truthfulness Scale score. The Truthfulness Scale can be interpreted independently. The Truthfulness Scale score overrides all other SE scale scores.

Suicide Scale: In almost every act of suicide, there are hints of suicidal thinking before the suicide occurs. Currently, one of the major obstacles in suicide prevention is not remediation, rather it is in identification (Suicide Prevention Resource Center, 2007). Most individuals who are contemplating suicide are acutely aware of their intentions. On the other hand the suicidal person may be unaware of their own lethality. Yet, they usually give many hints of their intention. Most suicidal acts 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. Yet, in almost every case there are precursors to suicide. Recognizing these clues is a necessary first step in suicide prevention. The Suicide Scale in the SE assesses verbal clues such as “I can’t stand it anymore” and behavioral clues like “successive approximations” with instruments of suicide like razors, pills, and the like: and moods like depression or emotional isolation. An elevated Suicide Scale score can reflect early symptoms of emotional detachment, defiance and loss of interest or withdrawal. Substance (alcohol and other drugs) abuse is often associated with the suicidal act (Gossop, 2005; Sher, 2005; Cherpitel, Borges & Wilcox, 2004; Hufford, 2001; May, Van Winkle, Williams, McFeeley, DeBruyn & Serna, 2002).. 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 and “giving up” or “internalization.” Although depression is the most recognized prodrome for suicide - it is not the only one. Consequently, the presence of emotional or mental health problems should not be ignored. To accurately identify suicidal individuals, we must combine separate symptoms when no one symptom by itself would necessarily be a good suicide predictor. And to a large extent that is what the SE does. When you have an elevated Suicidal Scale score, particularly in the severe problem (90 to 100th percentile) range, with another elevated scale score the assessor must consider suicide a possibility and take appropriate steps. The higher the scores, the more serious the situation. Appropriate steps could include alerting other staff, obtaining a consultation, promptly referring the client to a licensed mental health professional or requesting a comprehensive psychological evaluation (Suicide Prevention Resource Center, 2007). The assessor’s judgment and experience will influence the decision involving the client’s family, friends and support group.

Depression Scale: measures the severity of depression. Depression is a complex term. Some assessors use the term “depressed mood” which refers to a state of non-clinical melancholia, whereas others refer to “clinical depression” which is disruptive to a person’s social functioning and activities of daily living. Depression is a common disorder among suicidal individuals (Brent, Kolko & Birhamer, 1998; Pearson, Conwell & Lyness, 1997) and is known to be a major risk factor for suicide (NIMH, 2011; Mann, et al., 2005). Depression Scale scores in the problem risk (70 to 89th percentile) range are more characteristic of a depressed mood, yet they could be symptomatic of the early stages of depression. A severe problem (90 to 100th percentile) Depression Scale score is indicative of a clinical depression and the patient might be referred for a psychological examination. Concurrently elevated scales, particularly in the severe problem (90 to 100th percentile) range are a malignant sign and contribute to problem complexity. An elevated Depression Scale score with an elevated Suicide Scale score is particularly problematic regarding suicidal ideation. A concurrently elevated Alcohol Scale and/or Drugs Scale score would be of concern because substance abuse impairs judgment and can exacerbate symptomatology. Impaired stress coping abilities would only further increase elevated scale score problem severity. The Depression Scale can be interpreted independently or in combination with other Suicide Evaluation (SE) scales.

Alcohol Scale: measures alcohol use and the severity of abuse. Alcohol refers to beer, wine and other liquors. Alcohol abuse is linked to suicide (Gossop, 2005; Sher, 2005; Cherpitel, Borges & Wilcox, 2004; Hufford, 2001; May, Van Winkle, Williams, McFeeley, DeBruyn & Serna, 2002). 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 (e.g., alcohol-related arrests, DUI/DWI convictions, etc.) could result in an abstainer (current non-drinker) attaining a low to medium risk scale score. Consequently safeguards have been built into the SE to identify “recovering alcoholics.” Severely elevated Alcohol and Drugs Scale scores indicate polysubstance abuse and the highest score usually identifies the individual’s substance of choice. Scores in the severe problem (90 to 100th percentile) range are a malignant prognostic sign. Elevated Alcohol Scale, Drugs Scale and Suicide Scale scores are a particularly dangerous combination. Here we have a suicidal individual who is even further impaired when drinking or using drugs. Stress exacerbates emotional and mental health symptomatology and alcohol abuse magnifies these problems even further. Consequently, alcohol abuse magnifies the pathology associated with SE scales. In intervention 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 SE scales.

Drugs Scale: measures drug (marijuana, ice, crack, cocaine, amphetamines, barbiturates and heroin) use and severity of drug abuse. An elevated (70 to 89th percentile) Drugs Scale score identifies emerging drug problems. Some depressed or emotionally disturbed individuals may use drugs to achieve an altered state of mind (Tart, 1969; McPeake, Kennedy & Gordon, 1991) and as a way to cope. A Drugs Scale score in the severe problem (90 to 100th percentile) range identifies established drug problems and drug abuse. A history of drug-related problems (e.g., drug-related arrests, drug treatment, etc.) could result in an abstainer (current non-user) attaining a low to medium risk Drugs Scale score. For this reason precautions have been built into the SE to insure correct identification of “recovering” drug abusers. Concurrently elevated Drugs Scale and Alcohol Scale scores are indications of polysubstance abuse, and the highest score reflects the individual’s substance of choice. A very dangerous situation is identified when both the Drugs Scale and the Suicide Scale are elevated. A Drugs Scale score in the severe problem (90 to 100th percentile) range should be taken very seriously. Drug abuse can exacerbate suicidal ideation and impair judgment. Elevated Drugs and Depression Scale scores may represent attempts at self-medication, whereas severe scores may represent suicidal thinking and acting out potential. The more of these scales that are elevated with the Drugs Scale the more problem prone the client’s situation becomes. The Drugs Scale can be interpreted independently or in combination with other SE scales.

Stress Coping Abilities Scale: measures the individual’s ability to cope effectively with stress, tension and pressure. How well a person manages stress affects their overall adjustment. Poor stress management has been linked to suicide (Amir, Kaplan, Efroni, & Kotler, 1999; Thompson, Kaslow, Kingree, Puett, Thompson & Meadows, 1999; de Man, 1988). A Stress Coping Abilities Scale score in the elevated (70th percentile and higher) range provides considerable insight into co-determinants while suggesting possible intervention programs. A score in the severe problem (90 to 100th percentile) range often means the client should be referred to a mental health specialist for further evaluation, diagnosis and a treatment plan. 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 and perilous situation involves an elevated Stress Coping Abilities Scale with an elevated Alcohol Scale, Drugs Scale or Suicide Scale. Poor stress management abilities along with substance (alcohol or other drugs) abuse in a suicide-prone individual defines high 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 SE scales.

Citations

Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide risk and coping styles in post-traumatic stress disorder patients. Psychotherapy and Psychosomatics, 68(2), 76–81.

Brent, D.A, Kolko, D.J, Birhamer, B., et al. (1998). Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. J Am Acad Child Adolesc Psychiatry 1998; 37:906-14.

Cherpitel, C.J., Borges, G.L., Wilcox, H.C.(2004). Acute alcohol use and suicidal behavior: a review of the literature. Alcohol Clin Exp Res 2004; 28(Suppl.):18–28S.

de Man, A. F. (1988). Suicide ideation, stress, social support, and personal variables inFrench-Canadians: A structural analysis of relationships. Journal of Social Behavior and Personality, 3, 127-134.

Gossop M. (2005). Alcohol in suicide attempts and completions. Psychiatric Annals 2005; 35:513–21.

Hufford, M.R. (2001). Alcohol and suicidal behavior. Clin Psychol Rev 2001; 21:797–811.

Mann J.J., Apter A., Bertolote J., et al. Suicide prevention strategies: A systematic review. JAMA.2005;294(16):2064-2074.

May, P.A., Van Winkle, N.W., Williams, M.B., McFeeley, P.J., DeBruyn, L.M., Serna, P. (2002). Alcohol and suicide death among American Indians of New Mexico: 1980–1998. Suicide Life Threat Behav 2002; 32:240–55.

McPeake, J.D., Kennedy, B.P., Gordon, S.M. (1991). Altered states of consciousness therapy: a missing component in alcohol and drug rehabilitation treatment. Journal of Substance Abuse Treatment, 8; 1-2: 75-82.

National Institute of Mental Health (NIMH) website: http://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml

Pearson, J.L., Conwell, Y., Lyness, J.M. (1997). Late-life suicide and depression in the primary care setting. In: Schneider LS, editor. Developments in geriatric psychiatry. New directions for mental health services (no. 76). San Francisco: Jossey-Bass:1997:13-38.

Sher, L. (2005). Alcoholism and suicidal behavior: a clinical overview. Acta Psychiatr Scand 2005; in press.

Simon, R. (2002). Suicide risk assessment in managed care settings. Primary Psychiatry, 9(4):42-49.

Suicide Prevention Resource Center. (2007) Best Practices Registry for Suicide Prevention Fact Sheet: Warning Signs for Suicide Prevention. Newton, MA. http://www.sprc.org/featured_resources/bpr/PDF/AASWarningSigns_factsheet.pdf.

Tart, C., ed. Altered States of Consciousness. New York: Wiley, 1969.

Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic stress disorder as risk factors for suicide attempts in a sample of low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59–72.