Suicide Assessments: The Medical Profession Affirms School Counselors' Truth

In the school counseling world of gray, there is one truth that is a constant; school counselors know they cannot accurately assess suicide risk. Unequivocally, school counselors recognize they aren’t equipped to assess a student’s level of suicide risk, and to imply that we can is unethical and elevates our skills above medical professionals, who are themselves declaring in large numbers the danger, fallacy and inaccuracy of classifying a person for suicide. If the medical profession is questioning suicide risk assessments as untrustworthy, by reasonable extension those who require school counselors to assess a student’s suicide potential do so at the risk of liability.

During the last decade, a growing body of research in the medical and mental health field on the predictive ability of suicide assessments has validated what school counselors have always known – suicide risk assessments are too inaccurate to be trusted. Medical and clinical researchers are examining the efficacy of assessments and concluding that despite substantial efforts, assessments have no predictive value. Risk stratification misses many cases with a very high false-positive rate. In 2017, research by Large, et al. examined 40 years of suicide risk assessment research. Ninety-five percent of patients assessed as high risk did not die by suicide; however, 50 percent of patient suicides assessed in lower risk categories did die by suicide. In 2018, a study of 157 patients who died by suicide found that 67% of the deceased had denied suicidal ideation during an assessment given within two days of their death. 

In a 2016 American Psychological Association meta-analysis report, researchers concluded assessments were as powerless as random guessing. “Experts’ ability to predict if someone will attempt to take his or her own life is no better than chance and has not significantly improved over the last 50 years. ... Our analyses showed that science could only predict future suicidal thoughts and behaviors about as well as random guessing. In other words, a suicide expert who conducted an in-depth assessment of risk factors would predict a patient’s future suicidal thoughts and behaviors with the same degree of accuracy as someone with no knowledge of the patient who predicted based on a coin flip.” 

Assessment Dangers
As the medical and mental health professions continue to debate the efficacy and accuracy of their efforts to assess suicide, one thing is certain – school counselors should never be required to predict if a student is safe from suicide based on an in-school assessment. Many school counselors don’t need research to tell them this truth as they have first-hand, heartbreaking proof that school counselors aren’t able to predict safety based on a student’s self-report. School counselors rely on experts in the medical and mental health fields to use multiple means to attempt to unpack a student’s future likelihood for suicide, and the debate would suggest that even these esteemed professionals are far from agreement that they can assess suicide. 

Despite the dangers, school districts in America continue to impose on school counselors the impossible task of stratifying the lethality of suicide into the categories of low, medium and high risk based on a student’s self-report. How is it they can’t see how impossible this task is? Yes, school counselors can gather information to convey to parents, but the risk of assessing and being wrong outweighs any advantages in saying a student is low risk for suicide. The principles as established in Eisel v. Board of Education of Montgomery County, 1991, have informed the norms, customs, mores and values regarding school counselors’ role in assessing suicidal students and have been written in the ASCA Ethical Standards for School Counselors.  Specifically, the “do not negate the risk of harm” code has been part of the ethical standards since 2010 and also appears in the 2020 ASCA position statement The School Counselor and Suicide Risk Assessment.

Explain to all those who would impose suicide assessments on you that to quantify a student as low risk is to abandon the norms of the profession. Explain the dangers of using an anemic tool in such a powerful and dangerous way.

In addition to the principles established by the Eisel case, lessons learned from the Mikell v. School Administrative Unit 33 (2009) and the Rogers v. Christina School District (2012) court cases have been included into the ethical standards as well, making it painfully clear the fallacy and danger of labeling a child’s risk of suicide as low or nonexistent. 

Suicide assessments by school counselors are inaccurate at best and dangerous at worst, especially for the few outliers in our profession who believe they can actually assess children and deem them low risk. An assessment should add to the body of gathered information and should not state or imply to parents their child’s level of risk has been determined. School counselors who use suicide assessments to quantify a low risk are operating completely outside their competence, qualifications, ethical imperative and standard of care.

In isolation, an assessment is simply what the student chooses to reveal. Students often hide the truth or vacillate about whether to reveal the truth to the adults in their lives. There are many reasons why a student may deny self-harm. The competent school counselor would never conclude students weren’t in danger simply because they said they are fine. The common-sense approach would be to dismiss all self-reports denying harm as untrustworthy. Avoid trying to reach conclusions through questioning from an assessment; instead, gather all the information you can to pass to a student’s parents/guardians. 

School counselors have historically had an instant, deeply ingrained reaction to any potential suicide report, whether the source of those reports is self-report, peer report, rumors, staff/faculty or hearsay. Peer reports, unlike self-reports, are more likely to contain the truth, as adolescents tend to confide in peers more than adults as they move through puberty. If a peer tells you another student is possibly suicidal, ethical practice requires school counselors to put considerable weight on the report, provide the parents with an explanation as to how you came to be informed and emphasize the value of peer reports. 

If after receiving a peer report and speaking with the student alarm bells don’t go off, don’t trust it. Communicate with the student’s parents and explain what precipitating events or persons led you to do speak with their child. If it was because of a peer report, be certain to stress to parents that truth is often found in peer reports. 

Peer pressure, social isolation and loneliness are areas to explore with the parents/guardians, as well as any stressors you know of that their child may be experiencing, such as high expectations, perfectionism, bullying, friendship woes, social media conflicts, indirect and/or direct threats, etc. Students who make suicide threats often give indirect indicators of suicide instead of directly saying, “I am going to kill myself.” For example, “I wish I could float away and never come back” or “I am a horrible person, and I am going to do something about it” are examples of indirect threats. Ask parents to investigate their child’s social media, phone, writings and/or room. Parents are in the best position to unpack clues in areas where you don’t have access, and mental health professionals are in the best position to help the student in multiple sessions focusing on healthy and unhealthy coping mechanisms.

No Second Chances
The complexities of suicide cannot be reduced to a rating or a category. Never allow parents to believe that the title of school counselor carries with it clinical skills and qualifications in assessing suicide. There is no loss of dignity, integrity or statue in admitting your limitations in such a critical issue. In fact, you show strength and a strong sense of responsibility when making certain parents understand the fallacies of in-school suicide assessments. 

Give parents information, and avoid the temptation to reassure them or minimize the risk. This is not the time to worry about what stress or alarm you may cause the parents; rather, it is a time to provide resources and information with the caveat that you are absolutely unable to tell them if their child is safe. Word choice and urgency are important. Parents need to hear the straightforward message of suicide, no couching in words such as “impulse control” or “hurt oneself.” Parents are looking to you for reassurance in your content, tone, cadence and words that their child is safe. You can’t give them what you don’t have or assure them all is well. Label the potential harm as suicidality and hope you are wrong, but don’t soft pedal it and hope you are right. A sense of urgency to parents is always a safer alternative than a soft message. Given the possible consequence of death of a child, intensity over moderation is a better approach.

Assessing preadolescents for suicide is extra challenging. Research tells us that the typical assessment questions such as, “Have you thought about killing yourself?” or “Do you have a plan?” are all likely to be answered “no” by preadolescents. Researchers in the medical field are trying to find appropriate ways to assess the preadolescent and bemoan the deficiency of suicide-specific screening tools that can be used for this age group; however, school districts aren’t making any concessions for the age group. 

School counseling professionals must educate all those who want to impose assessment duties on them. Recently, I worked with an external community group who vigorously defended the need to quantify suicide levels and developed an assessment for school counselors to use. The hair-pulling piece is that this group, external to the school, will not be held responsible if something goes awry; it will be the district and the school counselors. How do we stop other student services personnel and external groups from imposing these dangerous practices on the profession? 

If you have advocated against quantifying the lethality of suicide and lost the battle, win the war. Use politically astute language and refuse to negate the risk. Use any number of disclaimers in place of “low risk,” such as “unable to assess”; “not enough information”; “unknown, as self-reports are invalid”; “student was not forthcoming”; “peer reports supersede student denial, and this assessment is not as valid as the peer report I received”; “I am not qualified to accurately assess, as it takes multiple approaches and means from the mental health and medical field”; or “my ethical response is to recognize and convey to parents my limitations in knowing what is in your child’s head and heart. Seek outside mental health or medical help for your child.”

Suicide is devastating to all. School counseling professionals owe it to themselves, their district, their students and parents to get their response to suicidal ideation right. Often there are no second chances. Well-meaning but ill-informed advocates of quantifying suicide are placing all of the above at risk. The overarching role for the school counselor is simple; give parents all the information you can to enable them to exercise custody and control over their child. A powerful assessment negating a suicide and wrapped in the dangerous delivery of a friendly conversation has been at the heart of one-too-many court cases with school counselors at the center. If a school district expects or requires you to complete an assessment, remain in your competence level and within your ethical imperative to never assign a child’s lethality as low risk. Sound judgment tells educators, mental health or medical professionals that one can never know from a child’s self-report if they are getting the truth.

School counselors work with students who are developmentally all over the continuum, who rely more on peers as confidants than adults and who are in a setting designed for academic instruction. Suicidal students need a qualified mental health or medical professional who can spend the time needed to learn the history of the suicidal ideation, its context, its frequency/duration, how it has been handled to date, what protective factors are in place, how to increase protective factors and decrease causes. This approach is beyond the nature and function of schools.

School counselors have a very limited role in suicidal ideation. Receive and respond to the outcry, gather as much information to relay to parents as possible, notify parents, involve others to keep the student safe until parents arrive, provide resources, and try to determine if parents are taking the report seriously. Note, there is nothing here about predicting a child’s future.