Using the Scale

General Questions and Misconceptions

Who can use the Columbia Protocol?

Anyone can use the Columbia Protocol; no mental health training is required. The wide variety of Columbia Protocol users includes physicians and nurses, first responders, psychologists, social workers, counselors, correctional officers, research assistants, high school students, teachers, family members, and clergy.

Do I need training to use it?

No technical training is required unless you are using the Columbia Protocol for research. We do suggest training for users, however, and offer several easy options, including online sessions that take as little as 20 minutes to complete.

What ages are the scales for?

The standard version of the C-SSRS is suitable for most children and adults. While developed initially for adolescents in the first suicide attempters study. The standard C-SSRS has been successfully used with children age 6-12 as is documented in many studies in our evidence book. Many younger children can understand the concepts of the questions as they are worded in this standard version.

There is a version of the full C-SSRS scale for very young children aged 4-5 that was developed via expert consensus. It measures the same constructs and scores basically the same as the regular scale but provides additional ways of asking the questions (probes) for the youngest children (4/5) and those at a very young cognitive age (e.g. “Have you thought about how to make yourself not alive anymore?”) Another example is in the intent to act question. Instead of “Did you intend to…” it says “Did you think this was something you might actually do?”

Furthermore, the Ideation Intensity section only includes the frequency question as concepts like controllability and duration likely may not be understood. Another modification is the wording of the behavior section. Preschoolers, ages 4-5, typically understand the concept of suicide but do not engage in many of the common preparatory behaviors such as writing a will.

Additionally, one of the fundamental tenets of the C-SSRS is that it encourages the integration of multiple sources of information if useful. Third parties (i.e., parents, teachers, caregivers, medical records) can provide additional information to help complete the assessment if the child is unable to answer any of the questions or if more accurate information can be gathered making it usable for even the youngest children.

Which form of the protocol should I use?

Our Columbia Protocol webpages for families, friends, and neighbors; healthcare and other community settings; and research will help you select the appropriate form of the protocol for your situation.

Is suicide really preventable?

Yes. Most people are suicidal for only a short time, so helping someone through a suicidal crisis can be lifesaving. Multiple studies have found that more than 90% of people who have made the most serious suicide attempts do not die by suicide. When people are suffering, they want help.

Does asking people about suicide put the idea into their heads?

No, and for people who are considering suicide it can actually be a relief to talk about it. A seminal study by one of the Columbia Protocol developers — published in 2005 in the Journal of the American Medical Association — found that if you ask high school students about suicide, it doesn’t cause them to become suicidal or even distressed. For depressed students, asking the questions actually lowered their distress.

A review of all 13 research papers on this issue that were published from 2001 to 2014 found that none showed a statistically significant increase in suicidal ideation. According to the resulting report, “Our findings suggest acknowledging and talking about suicide may in fact reduce, rather than increase suicidal ideation, and may lead to improvements in mental health in treatment-seeking populations.”

If someone intended to attempt suicide, why would that person tell you?

Real-world experience shows that many people with suicidal thoughts will tell someone about thoughts of suicide when asked — and they consider it a relief to talk about it. Even if they won’t tell a clinician or counselor, many people drop hints or give warnings to friends and family, because almost everyone considering suicide is ambivalent about dying. This characteristic ambivalence can make people who are thinking about suicide more willing to discuss their thoughts.

How can asking the Columbia Protocol questions help me allocate my available resources?

Experience and research show that the Columbia Protocol helps redirect resources to use them more efficiently. That’s because the use of the Columbia Protocol reduces “false positives” — that is, incorrectly identifying someone as at risk for suicide — even as it detects at-risk individuals who would otherwise have been missed.

When the protocol does identify people who are at risk, it helps healthcare workers, first responders, and other gatekeepers direct them to the appropriate level of care, such as counseling. Sometimes hospitalization is required, but it’s rare: Our experience with the Columbia Protocol consistently shows that 1 to 2% of people screened with the protocol require more acute care — even among high-risk populations such as people with depression and veterans with a psychiatric diagnosis.