Suicide refers to the act of intentionally taking one’s own life while self-harm is the act of intentionally injuring oneself. Although self-harm such as intentionally cutting oneself can be associated with suicidal ideation, it is also known to be an impulsive behavior used by many as a way of attempting to cope with emotional pain. The National Center for Injury Prevention and Control reported that in 2016, suicide was the 10th leading cause of death in the United States for all ages. In 2016, there were nearly 45,000 suicides in the United States, and 9.8 million adults reported having suicidal thoughts at some point during that same year. Suicide has been estimated to cost more than US$50 billion in combined medical and work loss. Self-harm such as cutting and burning oneself are on the rise, and hospitals have reported an increase in the number of adolescents and young adults hospitalized for self-harm. Given these facts, it is not surprising that researchers have spent much time and energy over the years developing tools that help to screen for risk factors related to suicide and self-harm.
Risk Factors for Self-Harm and Suicide
Research has pointed to a number of factors that are correlated with self-harm and suicide. Based on epidemiological data, most cases of self-harm involve cutting behavior by adolescent females. People who commit suicide are more likely to have a mental illness, a family member who has committed suicide, or a history of drug and/or alcohol abuse. Although people without mental illness have been known to commit suicide, the majority of people who commit suicide have a mental illness, primarily a depressive disorder. Consistent with a cognitive behavioral model of mental illness that proposes that a person’s feelings and behaviors are a response to errors in thinking and a faulty belief system, people who engage in suicidal behavior have been found to have some common beliefs that fall into one of three categories: that suicide is the only solution to their problems, that loved ones are better off without them, that they deserve to die, or a combination of all three. For self-harm behaviors such as cutting or burning oneself, risk factors may include peer or parental conflict, depression, personality disorders, or a combination of multiple factors. Understanding these correlates of suicidal behavior and self-harm has helped to guide the development and format of screening tools designed to assess risk of these behaviors.
Introduction of Screening Tools
One of the first paper-and-pencil screening tools that offered a numerical value to assess depression was the Beck Depression Inventory, developed in 1961 by Aaron Beck. This 21-item multiple choice assessment relies on endorsements that measure the presence and severity of certain thoughts and feelings that have been found to correlate with depression. While researching the Beck Depression Inventory, Beck found that people who reported stronger feelings of hopelessness were more likely to be suicidal. This discovery led Beck to publish the Beck Hopelessness Scale, a screening test that more specifically assessed feelings of hopelessness, which Beck believed to be a strong predictor of suicidal ideation.
As research into suicide and self-harm has progressed, numerous screening tools have emerged to assist health practitioners. Moreover, self-harm is no longer viewed as a precursor to suicide. It certainly can be; however, self-harm behavior is beginning to be understood as a clinical phenomenon quite separate from suicide. In addition, research finds that risk of suicide and self-harm varies depending on a number of demographic variables (e.g., age, sex, ethnicity) as well as situational variables (e.g., mental illness, stressors, drug abuse). As a result, screening tools have been developed to assess suicide and self-harm risk across a variety of demographics and situations.
Current Screening Tools
Most often, the best way to assess for self-harm or suicide is to simply ask the individual directly. However, in many cases, it is not possible to do so. For example, some people are embarrassed or ashamed to respond to direct questions. Also, there are situations such as when dealing with groups of people (e.g., patients at medical facilities, inmates at prisons, students in academic settings) when individual verbal assessments are not feasible. Consequently, it is useful to have screening tools that can help mental health professionals identify individuals at risk of self-harm and suicide. Although a simple Internet search might yield numerous hits that describe screening instruments designed to identify individuals at risk of self-harm and suicide, readers are cautioned that a screening instrument that claims to accurately predict risk of dangerous behaviors must be valid and reliable. In other words, the authors of a good screening instrument should provide empirical evidence that the screening tool accurately measures what it claims to measure.
In order to ensure that screening tools accurately assess risk of suicide and self-harm, they must be studied with regard to their validity and reliability. Validity refers to the extent to which the screening tool measures what it is intended to measure. For example, if a tool claims to measure one’s risk of self-harm, there must be clear definitions of what self-harm actually means. Does pinching oneself until it hurts constitute self-harm or is some type of physical injury as a result of the pinching necessary? Most authors report two types of validity to support the value of their assessment tool. The first is called construct validity, and typically, a screening instrument will be accompanied by evidence (usually in the form of a statistical correlation value) that across several studies using different participants, all participants understood the term or construct (i.e., self-harm) in a similar way. The second type of validity commonly reported is concurrent validity. Concurrent validity refers to how strongly the tool correlates with other tools that measure similar constructs and have been previously endorsed as having strong validity.
Having strong reliability is another important measure of a good screening tool. Most authors report a form of reliability called internal consistency reliability. To establish this, the individual items that make up the screening instrument are rearranged to mix up the order in which they are presented. For example, if the screening tool has 20 items and the original form is numbered 1–20, the same items might be split in half and presented in various orders to be sure that the individual items, regardless of the order, are contributing to the same outcome. There is a mathematical way of doing this and coming up with an average result for all the possible orders called Cronbach’s α—a single index reflecting the tools reliability.
Although there are hundreds of screening instruments, both formal and informal, available on the Internet, the following list of suicide and self-harm screening instruments represents a sample of those that have been subjected to scientific research and have demonstrated good validity and reliability for their respective areas of focus.
References:
- Mills, J., & Kroner, D. (2005). Screening for suicide risk factors in prison inmates: Evaluating the efficacy of the depression, hopelessness and suicide screening form. The British Psychological Society, 10, 1–12.
- Perry, A., Coulton, S., & Johnson, M. (2010). Screening tools assessing risk of suicide and self-harm in adult offenders: A systematic review. International Journal of Offender Therapy and Comparitive Criminology, 54, 803–828. doi:10.1177/0306624X09359757