Guidelines on suicide care from national organizations such as The Joint Commission provide recommendations on suicide risk assessment. Implementing these in health care settings rapidly leads to an array of administrative questions. Who should conduct the assessment? What is the optimal clinical tool? How often should the patient be assessed?
Because we work in complex systems, answers to these questions are necessary to support consistent care. Here, I hope to balance these administrative questions of who, what, and how with a focus on the therapeutic question of why to conduct a suicide risk assessment. If we have an outcome in mind of a range of options to support a patient at risk of suicide – i.e. the why of assessment – this will influence what information we want and how to obtain it – i.e. the what and how of assessment.
The Purpose of Suicide Risk Assessment
Suicide risk assessment is not known to predict suicide or to provide useful categories of low, moderate or high risk to guide clinical interventions. As such, national guidelines outside of the United States have recommended a shift from “risk assessment” to individualized “needs assessment” that works with patients to determine what is needed to maintain physical and psychological safety.
From this principle, I will offer a statement on the purpose of suicide risk assessment: The purpose of a suicide risk assessment is to gather information for shared decision-making in developing an individualized, dignifying and respectful plan to manage suicide risk. The management plan will include specific interventions drawn from four broad categories of intervention: facilitating connectedness, addressing mental health and substance use disorders, safety planning, and reducing access to lethal means. Below, I will expand on these categories.
Facilitating Connectedness
Facilitating connectedness refers to our efforts to promote connections and supports that direct the patient towards life. The suicidal state has been characterized as an experience of “mental pain or anguish and a total loss of self-respect.” When we facilitate connectedness, we try to convey a sense of belonging, value and hope to provide relief from these negative emotional and psychological states. During a suicide risk assessment, this means inviting the patient to “tell the story” of how the current crisis developed. Listening with open attention conveys messages that I’m here with you, you matter to me, and I have hope for you. As the patient talks, we will listen for opportunities to facilitate connectedness based on their background, circumstances, mental health symptoms, and existing strengths.
For example, the Trevor Project provides 24/7 crisis support for LGBTQ+ youth. For patients whose circumstances include actions that have damaged or destroyed relationships, a clinician’s compassionate engagement with devastating shame can represent a crucial inflection point that begins to restore dignity and hope. Patients with psychiatric symptoms might benefit from referrals for medication treatment and psychotherapy to decrease isolation and increase hope. Patients who prioritize spiritual coping can be engaged to explore how connections to internal images, metaphors and beliefs and external rituals and communities might support coping and a pathway towards recovery. Patients who refuse treatment remain candidates for connectedness-based interventions. For example, the caring letters intervention demonstrated that non-demanding caring contacts – simply conveying care and support without any expectations from the patient – reduced suicide deaths by approximately half among patients who declined treatment.
Addressing Mental Health and Substance Use Disorders
Some suicide decedents – though not all – have been found to have psychiatric or substance use disorders. Regardless of whether a patient meets criteria for a specific mental disorder, addressing psychiatric symptoms and substance use represents an important aspect of managing suicide risk. When present, anxiety, agitation, and insomnia might represent particular priorities. Addressing mental health conditions may have different benefits for suicide risk. For some patients, simply learning that they have a diagnosis with effective treatments available provides de-stigmatizing relief that counters isolation, worthlessness, and helplessness. Alternatively, effective control of severe psychiatric symptoms might provide stability to participate in psychotherapy to focus on suicide-related thoughts of despair and self-hate. For others, effective treatment of a mental disorder reduces the destructive, alienating effects that the symptoms may have had on relationships.
Existing treatment settings for substance use disorders can also be a place for patients to learn how to recognize and respond to suicide risk in themselves or peers, an online training for $100. During a suicide risk assessment, we will listen for the patient’s background to learn of any history of mental health treatment and for current psychiatric symptoms and/or substance use, as this information will help us discuss treatment options with the patient. Patients who refuse treatment for mental disorders remain candidates for interventions targeting ambivalence, such as motivational interviewing. For example, exploring the pros and cons of medication treatment with a patient with opioid use disorder would be considered an intervention for suicide risk by addressing an important risk factor for suicide.
Safety Planning
Safety planning refers to the process of collaborating with a patient to generate coping strategies for use during periods of elevated suicide risk. “Brand name” safety planning interventions include Crisis Response Planning and the Safety Planning Intervention. While these interventions result in a written document that details personal warning signs of a crisis and coping strategies, both of them hinge on an initial narrative interview during which the patient is invited to “tell the story” of a recent suicidal crisis. The clinician then reflects back what the patient has described, highlighting that suicidal crises are time-limited events with a beginning, middle and end. The crises include intoxicating, preoccupying thoughts of suicide, wrenching emotional states and urges to bring an end to suffering by ending one’s life. This shared understanding of the nature of suicidality forms the foundation of safety planning: Do you see how the risk goes up and then comes down? I want you to feel confident with choices and skills to survive those dark moments so that we’ll have time to work on the longer-term problems that have caused so much pain. During a suicide risk assessment, we will listen for specific crises and details of circumstances, thoughts, negative emotional states and actions. We will also listen for strengths and resources the patient has used to cope with crises. This information will help us discuss with a patient their personal warning signs of a crisis and potential coping strategies.
As described here, safety planning occurs as a collaborative process where the patient participates in self-recognition and self-management of suicide risk. For some patients, the extent of their suicidal preoccupation precludes the ability to maintain safety independently. For these patients, a higher level of care in an inpatient setting may be needed for external support. During a suicide risk assessment, we will listen for the patient’s level of suicidal intent and planning to inform whether the patient has the willingness and ability to self-manage suicide risk with safety planning. Patients who refuse collaborative safety planning remain candidates for receiving information about crisis resources and when to use these: These are two resources that can help when people feel overwhelmed and have thoughts of suicide. One is 988 Suicide and Crisis Lifeline where you or a loved one can talk with a crisis counselor; the other is the Crisis Text Line where you can text with a crisis counselor.
Reducing Access to Lethal Means
The “means” for suicide refers to the tools, instruments or objects that can be used to inflict self-injury. When people at risk for suicide do not have ready access to lethal means for use in a suicide attempt, this allows time to pass for a crisis to resolve and for risk to decrease. In lethal means counseling, clinicians have collaborative discussions with patients to motivate actions that reduce access to lethal means: I’m glad we’re talking today, and I believe your life can get better. A concern I have is that it sounds like there are times when the suicidal thoughts are especially intense. During those times, if you have immediate access to [means] we might lose you before we have enough time to work on the problems in your life. Can we talk about some ways to reduce your access to [means] so that you can survive to see things improve?
For firearms, which are especially lethal when misused in suicidal behavior, culturally-aligned counseling optimally occurs in a dignifying and respectful manner that resonates with the patient’s values. In Washington, it is legal to transfer firearms out of the home temporarily to manage suicide risk. For medications, clinician-initiated changes may also play a role: reducing the dose or amount dispensed of medications, selecting medications with lower toxicity, or discontinuing medications. During a suicide risk assessment, we will listen for background information that might suggest knowledge of or familiarity with particular means, suicide methods the patient has considered, and access to lethal means. In Washington, patients who refuse collaborative efforts to reduce firearm access and who are judged to be at high risk of harming themselves and/or others may be candidates for an extreme risk protection order as a legal process to recover firearms and prevent firearm acquisition.
Returning to “What” and “How”
In the sections above, I have described ways to manage suicide risk and the information needed from a suicide risk assessment to tailor these interventions for an individual patient. To summarize, we will need information about the patient’s background, life stressors, psychiatric symptoms, substance use, suicidal ideation, suicidal behavior, strengths and resources. In the language of risk assessment, these represent demographic, situational, symptomatic and suicide-specific risk factors, and protective factors.
To obtain this information in a way that facilitates connectedness and builds the rationale for safety planning, we will use a narrative interviewing technique that invites the patient to “tell the story” of how the current crisis developed: I’ll want to hear more about the suicidal thoughts, but first would you tell me (briefly) the story of what has brought you to think about suicide? Often the patient’s initial description does not include all of the elements of suicidal ideation and behavior we need to guide decision-making for managing suicide risk. To address this, we “back fill” with a suicide-specific assessment that asks specific questions about suicidal ideation, method, intent, planning, and suicidal behavior: Thank you for talking to me about this. I’d like to ask some specific questions about the suicidal thoughts, if that’s alright? With this range of information, we can proceed with shared decision-making to discuss a plan for improving safety using interventions from the categories previously described.
I hope this post has helped to clarify the role of risk assessment in suicide care. For future training opportunities and information on suicide care, please visit the Center for Suicide Prevention and Recovery.
Author
Jeffrey C. Sung, M.D.
Clinical Assistant Professor
UW Department of Psychiatry and Behavioral Sciences
Dr. Sung earned his M.D. at Northwestern University in Chicago, Illinois. His clinical interests focus on psychotherapy. He has taught psychodynamic theory, suicide risk assessment and managing response to patient suicide. Dr. Sung is a board certified psychiatrist and provides training and consultation through Forefront Suicide Prevention and the Center for Suicide Prevention and Recovery.
Learn More
Caring Contacts Training
This is a free one-hour, interactive, self-paced training course developed for medical professionals and client-facing staff in WA state, and open to everyone. It is designed to address the public health crisis of suicide and give providers and client-facing staff additional tools to prevent suicide.
Preventing Addiction Related Suicide (PARS)
PARS is a prevention intervention provided to addiction treatment patients who are at higher risk of suicide. The PARS web training costs $100 and is an interactive psychoeducational suicide prevention program that was designed to be used within community addiction group therapy treatment by addiction specialists and counselors, like SUDPs in Washington.
Suicide Risk Assessment and Documentation
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenters: Jeffrey Sung, MD and Amanda Focht, MD
The objectives of this presentation are to: 1) distinguish categories of risk and protective factors for suicide; 2) identify categories of intervention for management of suicide risk; and 3) describe components of suicide risk assessment and management documentation.
*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.