Suicide Assessment | Part 3 Formulate Risk and Plan for Safety
In Part One of this series on Suicide Assessment, I introduced a Framework to Guide Assessment based on the Four Core Principles used by 988 centers nationwide. In Part Two, I then explored how to gather the information needed for a full assessment, focusing on how to ASK about suicide, LISTEN to your client’s story, and CLARIFY missing pieces of your assessment. Here, in Part Three - the final part of the series - I will focus on how we use the information we have gathered to formulate the degree of risk that is present in order to PLAN with our clients for safety.
Risk Formulation
Once you have gathered your assessment data it's time to formulate the degree of risk you believe to be present - that is, how safe will your client be when they leave your office or end their online session? Your risk formulation integrates all the information gathered regarding your client’s immediate safety and available resources at a specific place and time.
It requires clinical judgment
Regardless of whether you used a standardized scale to gather data, you must conduct a detailed enough clinical assessment that allows for the client narrative - for them to freely tell their story - and for you to use your interviewing skills and clinical judgment to determine safety. There is no clear formula here. The goal is not to predict outcomes, which you cannot accurately do even with standardized scales (which I will discuss in a later post), the goal is to pause - to put it all together - to reflect on what it is you know and what it is that you can do to PLAN with your client for safety.
Formulating risk is an active, intentional pause to reflect on what we know and to begin the development of an individualized plan for safety.
The goal in formulating a risk status is the plan for safety.
In considering risk, most clinicians have been trained to categorize clients into high, moderate, or low risk for suicide (note that we would not say “no risk” as we have no real way of knowing). So we label the risk. But in practical terms, what does it mean to label a client as high, medium, or low risk for suicide? How useful is it?*
On its own, it doesn't help that much. Relying on simple labels at a single point in time, or treating the label itself as the endpoint or goal misses the point of the assessment. It fails to account for the fluid nature of suicide risk and the many factors in a person's life that can influence their level of risk over time. Most importantly it doesn’t guide us in what actions to take to ensure safety: So my client meets some established criteria for high-risk label, now what should I do?
For me, a more useful and practical approach to understanding my client's risk is to view that risk through the lens of a two-tiered stratification system. This framework considers both short-term (acute) and long-term (chronic) risk for suicide, which can better reflect the complexity of suicide risk and, more specifically, allow for a wider range of more meaningful interventions. This system also supports a more nuanced approach to documenting the rationale behind clinical decision-making. In private practice, knowing how to clearly articulate and justify decision-making is essential, not only for ensuring effective client care but for addressing the legal and ethical responsibilities associated with working with high-risk clients.
For Example
Your client expresses suicidal ideation, has a history of suicide attempts, and has a general plan for how they may act on these thoughts. Given this, they may meet established criteria for being at high risk for suicide (and when we think of high risk we often automatically think of needing an immediate intervention or hospitalization). But what if your client frequently presents this way, with suicidal ideation on an ongoing basis and a general plan for how they may act - but also they deny immediate intent, you have a strong relationship with your client, and the family is involved. The fact is that you do not believe they need to be hospitalized. But in documenting this it would not be accurate to state that they were at low or even moderate risk for suicide - which you may then have to defend should something happen. If they do make another suicide attempt, other clinicians may question why you described your client as low or even moderate risk when clearly they presented with SI, and a plan and suicide history. Similarly, if you document that they are high risk and something happens the question becomes: why didn't you hospitalize them? The fact is that such broad labels cannot accurately reflect the complexity and nuances that exist and do nothing to guide the intervention and care. [Adapted from Wortzel 2014].
One model that I find useful in practice**, which incorporates both a two-tiered system and focuses on actions to take, is the Therapeutic Risk Management Risk Stratification Table developed through the VA***. This model allows for a risk formulation that is flexible enough to meet client needs and helps align the clinical presentation with actions to consider as you PLAN for safety. In the table below, you can see how actions to take are aligned with available systems within the context of where the assessment occurs.
TABLE 1 - MIRECC Therapeutic Risk Management Risk Stratification Table [click here for pdf ]
Adaptations of this have been developed for a range of settings and in training clinicians I encourage them to modify this model to incorporate actions they will take in the context of their own practice.
Below is a snapshot of how I have adapted this model for use in my own practice. Grounded in the Four Core Principles of Assessment discussed in Part One, I detailed possible client presentations while emphasizing the actions I could consider for high, moderate, and low-risk scenarios across acute and chronic timeframes. In creating this resource, the terms “Guidelines to...” and “Actions to Consider...” were intentional and used to underscore its role as a flexible tool rather than a rigid formula. Presented in this way, it serves to guide my actions. It is important to acknowledge, however, that not all clients will neatly align with the categories provided, and it is not intended to replace clinical judgment or the individualized care essential for each client.
TABLE 2 - Adapted Therapeutic Risk Management Risk Stratification Table
Below is a breakout of acute and chronic high-risk and how these presentations might differ:
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A client at acute high risk - or what is often termed imminent risk - is largely a low-frequency occurrence. This client would likely express thoughts of suicide (DESIRE), have a plan, and engage in preparatory behaviors (INTENT). Their CAPABILITY to act may be enhanced by a history of suicide attempts but they would also have access to lethal means.and have a difficult time developing a meaningful safety plan.
Clients at acute high risk typically require hospitalization and encouraging your client to consider this will be the immediate concern. Your goal is always to collaborate with your client and facilitate the least invasive way they can access hospital care. Any involuntary actions should always be considered as a last resort and only when all other options have been exhausted. [An additional post will explore imminent risk further and the path to hospitalization - both voluntary and involuntary]
Essential Features
Suicide DESIRE with INTENT and CAPABILITY
Even if BUFFERS are present, they are likely insufficient
Unwilling or unable to develop a safety plan or to address access to lethal means
Assessment Presentation
Will likely express thoughts of suicide and have a plan - may have engaged in preparatory behaviors
Capability to act may be enhanced by having a history of attempts in addition to access to means
Likely be unable to sufficiently establish a safe environment due to emotional distress or high intent
May be experiencing acute psychosocial stressors (e.g., job loss, relationship dissolution, relapse on alcohol)
May be highly dysregulated with no real coping skills
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Clients that present as Chronic HIgh Risk can be extraordinarily stressful for clinicians. The most significant aspect here is that they are not at imminent risk and do not require immediate hospitalization (though there can be times that it is jointly determined that hospitalization would be helpful).
Clients may present with suicide DESIRE and INTENT but it is chronic and frequently stated. CAPABILITY may reflect previous attempts but, most importantly, they are willing to work on safety plan development and restrict access to lethal means. They also may be engaged in treatment and the focus of your therapeutic interventions will be on addressing thoughts of suicide and building coping strategies. In summary
Presenting Features
Chronic Suicide DESIRE and INTENT
Suicide CAPABILITY
Few BUFFERS
Willing and able to develop a safety plan
Willing and able to address access to lethal means
Suggested Actions to Maintain Safety
Develop a Safety Plan
Address access to lethal means
Emphasize 988 availability 24/7
Focus on building coping skills
Routinely assess suicide risk (ask about suicide)
Routinely update Safety Plan
In the adapted version above that I use in my practice, I have also written in key resources—such as contact numbers for local emergency rooms, mobile crisis teams (MCTs), and other referral options—that could be helpful. Having this printed and accessible assures that I have options to pursue when navigating stressful situations. I encourage you to develop an individualized plan for your practice, adding local resources and intervention options for clients at acute/chronic levels.
It is important to remember that while your risk formulation is an essential step toward developing a clear actionable plan, it should not alone dictate the care you provide. Your assessment and risk formulation together serve to inform your clinical decisions which ultimately, and ideally, should focus on prevention - not prediction.
The key question is not, How do I ensure my client won’t act on their suicidal thoughts?
Instead, ask,
What is the least invasive intervention I can provide right now to keep my client safe?
Remember
ASK about suicide
LISTEN to your clients suicide narrative
CLARIFY missing pieces (intent, capabilty, buffers)
PLAN for safety (risk formulation and intervention)
* There is an ongoing discussion within the suicide prevention community regarding the continued use (and value of) the categorization of risk into high, moderate, and low - with a particular emphasis on the use of these categories to predict outcomes or determine who gets care. I encourage you to read further on this issue if interested as it is too lengthy to present here in any detail.
** I am presenting one option here that I find useful in practice. I encourage you to also look at the approach taken by Tony Pisani and colleagues in the articles below, which outline how following your assessment, you can apply the information you have gathered into four distinct categories: risk status, risk state, resources, and possible impacts on risk.
*** The Therapeutic Risk Management model and its components are fully described in a series of ten articles published in the Journal of Psychiatric Practice. Read the articles in this series here.
Further Reading
Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry, 40(4), 623-629. doi:10.1007/s40596-015-0434-6
Turner, K., Pisani, A. R., Sveticic, J., O'Connor, N., Woerwag-Mehta, S., Burke, K., & Stapelberg, N. J. C. (2022). The Paradox of Suicide Prevention. Int J Environ Res Public Health, 19(22). doi:10.3390/ijerph192214983
US Department of Veterans Affairs. MIRECC/CoE. Therapeutic Risk Management
Wortzel, H. S., Homaifar, B., Matarazzo, B., & Brenner, L. A. (2014). Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract, 20(1), 63-67. doi:10.1097/01.pra.0000442940.46328.63
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