Week 7 Discussion

The Firestone Assessment of Self-Destructive Thoughts (FAST) is designed to measure the "Continuum of Negative Thought Patterns" as they relate to a client's level of self-destructive potential or suicidality. The authors recommend the FAST to be used for screening, diagnosis, treatment progress, treatment outcome, research, and therapy. The FAST is theoretically grounded in what the authors refer to as the "concept of the voice," which refers to negative thoughts and attitudes that are said to be at the core of maladaptive behavior.

The FAST consists of 84 items that provide self-report information from a respondent on how frequently he or she is experiencing various negative thoughts directed toward himself or herself. Four "composites" and 11 linked "continuum levels" comprise the FAST. One composite is named Self-Defeating and has five continuum levels (Self-Depreciation, Self-Denial, Cynical Attitudes, Isolation, and Self-Contempt). Addictions is another composite with addictions listed as its continuum level. A third composite is Self-Annihilating with four continuum levels (Hopelessness, Giving Up, Self-Harm, Suicide Plans, and Suicide Injunctions). The last composite is Suicide Intent and no continuum levels are identified.

ADMINISTRATION, SCORING, AND INTERPRETATION. The FAST instrument is a seven-page perforated, self-carbon form used for responding to items, scoring responses, and graphing the results. T scores are derived for the 11 continuum levels, four composites, and for the total score. Percentiles and 90% confidence interval bands also are available for use. The T scores are plotted on the T-Score profile graph, which has shaded partitions that indicate if the T scores fall within a nonclinical range, equivocal range, or clinical ranges that include elevated and extremely elevated.

The normative sample for the FAST was a clinical sample of outpatient clients undergoing psychotherapy. A T score of 50 on any scale represents the average performance of an individual who was in outpatient treatment with no suicide ideation from the normative sample. The nonclinical range is a T score between 20 and 41 whereas the equivocal range is 42-48. The two clinical ranges are elevated (42-59) and extremely elevated (60+). Any score that falls above the equivocal range is treated with concern and anyone scoring in the extremely elevated range on levels 7-11, the Self-Annihilating Composite, the Suicide Intent Composite, or the Total score should be immediately assessed for suicide potential.

DEVELOPMENT OF THE SCALES. The items for the FAST were derived from actual statements of 21 clinical outpatients who were receiving "voice therapy" in groups. Nine of the outpatients had a previous history of serious suicide attempts and the others exhibited less severe self-defeating behaviors including self-denial, isolation, substance abuse, and eating disorders. The list of items was further refined from a study conducted to select those factors that significantly discriminated between suicide attempters and nonattempters. Then items were retained or deleted based upon their psychometric relationship to hypothesized constructs, resulting in the current 84-item version of the FAST.

RELIABILITY AND VALIDITY. Cronbach's alpha reliability coefficients ranging from .76 to .91 (Mdn = .84) are reported for the 11 level scores. Standard errors of measurement and 90% confidence intervals also are provided. However, sample sizes and descriptions are not provided for these measures. Test-retest reliability coefficients (1-266 days) ranged from .63-.94 (M = .82) using a sample (N = 131) of nonclinical, psychotherapy outpatients, and psychiatric inpatients.

Content validity of the FAST was investigated using a Guttman Scalogram Analysis resulting in a coefficient of reproducibility of .91 and a coefficient of scalability of .66. FAST Total Scores were correlated with the Suicide Ideation subscale of the Suicide Probability Scale (r = .72) as indicators of convergent validity. An exploratory factor analysis was conducted using 579 outpatients resulting in a 3-factor solution (Self-Annihilating, Self-Defeating, and Addictions), which provided support for construct validity. Evidence for criterion-related validity was demonstrated from studies showing how FAST scores were able to discriminate inpatient and outpatient ideators from nonideators and to identify individuals who made prior suicide attempts.

SUMMARY. The authors have put forth empirical evidence that supports the psychometric properties of the FAST. However, continuing studies are needed, especially related to the effectiveness of the FAST in diagnosing and predicting chemical addictive behavior. Furthermore, the construct validity of scores from the FAST needs further consideration. First, the items for the FAST were generated from a small (N = 21) somewhat restricted focus group of persons receiving "voice therapy." Second, the FAST is closely anchored to a theoretical orientation known as "concept of the voice" in which additional studies are needed to validate.

Overall, the FAST is a measure worth considering for professionals working with individuals who have exhibited self-destructive potential or suicidality. However, I encourage professionals to study the theoretical orientation underlying the FAST and determine if it is congruent with their own expectations for clinical outcomes prior to extensive use of the instrument.

Review of the Firestone Assessment of Self-Destructive Thoughts by ROBERT C. REINEHR, Professor of Psychology, Southwestern University, Georgetown, TX:

The Firestone Assessment of Self-Destructive Thoughts (FAST) is a self-report questionnaire intended to provide clinicians with a tool for the assessment of a patient's suicide potential. Respondents are asked to endorse how frequently they are experiencing various negative thoughts directed toward themselves. The items were derived from the actual statements of clinical outpatients who were members of therapy groups in which the techniques of Voice Therapy were used.

Voice Therapy is a technique developed by the senior test author as a means of giving language to the negative thought processes that influence self-limiting, self-destructive behaviors and lifestyles. The FAST includes items intended to assess each of 11 levels of a Continuum of Negative Thought Patterns. Items were assigned to levels based on the judgments of advanced graduate students and psychologists with training in Voice Therapy.

In the standardization process, the FAST was administered to a sample of 478 clients who were currently receiving outpatient psychotherapy and who did not have any current (within the last month) suicide ideation, suicide threats, or suicide attempts. Standard scores were calculated for the Total Score, for four composite scores derived by factor analysis and other statistical procedures, and for each of the 11 levels of negative thought patterns.

Estimates of internal consistency are based on a single sample, the size of which is not reported in the manual. They range from .76 to .97, with the majority falling between .81 and .88. Test-retest reliability estimates are reported for three samples with intervals from 28-266 days in one study and 1-31 days in another: psychiatric inpatients (n = 28), psychotherapy outpatients (n = 68), and nonclinical college students (n = 35). Reliabilities for the various levels of the negative-thought continuum range from .63 to .94, with the higher coefficients generally being found among the nonclinical respondents. Test-retest reliability estimates for the various composite scores and for the total score are somewhat higher, ranging from .79 to .94.

As an indication of construct validity, FAST scores were compared to scores on the Beck Depression Inventory (BDI), the Beck Suicide Inventory (BSI), and the Suicide Probability Scale (SPS). The FAST Total score had its highest correlations with the BDI (.73), the BSI (.72), and the Suicide Ideations subscale of the SPS (.76). The composite scores and the various level scores had lower correlations with the subscales of the Beck instruments or the SPS.

The FAST was administered to groups of inpatients and outpatients with various diagnoses including Adjustment Disorder, Anxiety Disorder, Bipolar Disorder, Depression, Personality Disorder, Schizophrenia, and Substance Abuse, and to a nonclinical sample of 172 college students. Each of the clinical groups was further subdivided into suicide Ideators and Nonideators. Ideators had higher average FAST Total scores than did Nonideators and clinical groups had higher average FAST Total scores than did the nonclinical group. Information is provided in the manual with respect to the relationships between the various FAST subscales and the diagnostic groups and subgroups.

SUMMARY. In general, it would appear that the FAST is similar in many ways to other depression and suicide inventories. Total Scores tend to be higher for respondents in diagnostic groups than for nonclinical respondents, and within diagnostic groups, Suicide Ideators score more highly than do Nonideators.

Within the limits of these findings, the FAST may be useful to clinicians as an indication of how a given respondent's answers compare to those of various diagnostic groups. It might also be possible to use the scale as a clinical tool for the evaluation of change during therapy, although use as a psychometric instrument is not justified on the basis of the evidence presented in the manual.