Hal Wortzel, MD

A major component of suicide risk management is safety planning, which can help the clinician better understand targets for intervention. Is "risk stratification," designed to specify severity for both acute and chronic risk of suicide, an effective strategy?

A. Tends to emphasize static risk factors over dynamic risk factors and warning signs

D. Facilitates appropriate involuntary admissions while helping to avoid unnecessary hospitalizations

A major component of suicide risk management is safety planning. Planning can help the clinician better understand risk and targets for intervention (eg, that the patient is unable to identify warning signs and has limited coping skills) while also providing information about what types of management approaches may be indicated. It is critical to note the many pitfalls of the management approach of “no suicide contracts.”

These types of contracts, which essentially involve the patient making a commitment to not die by suicide until the next session or that he or she will not enact suicidal behavior without first contacting the clinician, have no evidence base behind their efficacy, afford no medicolegal protection, are not patient-centered, and can have paradoxical effects for both the patient (eg, less disclosure about suicidal desire to not disappoint the clinician) and the clinician (eg, false sense of security which leads to less engagement in appropriate management approaches).

In contrast, the safety planning process involves a hierarchical set of strategies designed to help a patient know how to identify and how to cope when in a suicidal crisis. A therapeutic risk management of the suicidal patient (TRMSP) framework is built on and integrates the tenets of prior research and clinical evidence, the ethical principles of autonomy, nonmaleficence, and beneficence, and medicolegal knowledge and awareness. TRMSP consists of three core components:

1. a clinical interview/suicide risk assessment that is augmented by an evidence-based structured instrument

2. stratification of risk by severity and temporality, and

3. a collaboratively developed safety plan

The TRMSP framework provides an alternate approach to the risk formulation by using a stratification across both severity and temporality. This allows for a more nuanced discussion of risk by enabling a clinician to simultaneously speak to chronic factors (ie, demographic risk factors, past suicide attempts, diagnoses) as well as acute presentation (ie, indicators of risk like preparatory behaviors, intent).

Suicide Risk Assessment and Management: Tips for Improving Care and Outcomes

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What are the core components of a therapeutic risk management framework for a suicidal patient? Find out in this quiz.

Mini Quiz: Suicide Risk Stratification

It is late Friday afternoon and you are about to see your last patient, Mr G. This morning, as you prepared for your third meeting with him, you jotted down notes about the need to review the benefits and potential side effects related to his new psychiatric medications and a reminder to check back in on the psychosocial stressors that seemed to be escalating for your patient when you saw him a few weeks ago. These stressors, in combination with chronic depression and anxiety, served as the catalysts to why he had come in to see you for the first time 2 months earlier. When you meet Mr G, you notice that his affect is more dysphoric than his previous presentations, with notable agitation and hopelessness that permeates the rest of your time together. He discloses that things have not gotten better and that he is starting to give up hope that things will ever get better. His marriage is “failing,” he might be laid off from work soon, and is feeling like a burden to others more and more each day.

Despite being a seasoned clinician, you feel a twinge of anxiety as you take in his comments. Your mind is moving quickly, and you know you need to get a suicide risk assessment under way. That natural anxiety does not dissipate. In fact, it becomes more intense when you gather the “results” of your suicide risk assessment.

The data confirm that your patient is positive for many suicide risk factors (eg, demographics, psychiatric diagnoses, chronic suicidal ideation, hopelessness, burdensomeness) and is clearly experiencing several psychosocial stressors that are exacerbating his clinical presentation and contributing to several warning signs (eg, isolation, trouble sleeping, agitation). He also discloses that his suicidal ideation has become more severe and frequent, that he has been thinking more about the plan for suicide he has always had in the back of his mind (overdosing via a highly lethal combination of medications to which he has access), and indicates intent for suicide as 3 out of 10 (0 = no intent; 10 = highest intent).

Although the patient’s current warning signs and suicide risk indicators (ie, ideation, intent, plan, access to means) suggest elevated risk, he is also openly disclosing and seeking support, all good signs. But you cannot ignore that his combination of historical/baseline factors suggests elevated risk for suicide. Your lack of a lengthy therapeutic relationship also complicates the suicide risk formulation. Weighing all of these factors, you eventually arrive at the decision that “moderate risk for suicide” is the best formulation but feel stuck about the optimal way to proceed.

When thinking about a case like this, determining how to ensure delivery of excellent care while balancing medicolegal demands may seem to be an impossible task. Recent increased attention to the alarming public health problem of suicide has led to greater discourse and new implementation strategies to prevent suicide. There remains an intimidating gap in empiric knowledge on how to determine, with any certainty above chance, who will die by suicide among those exhibiting risk. This dilemma-the impetus to eliminate suicides and a lack of clearly defined paths for how to arrive at that goal-naturally causes apprehension.

In fact, this issue has caused some suicide researchers to publish their reexaminations of what we know and do not know-an important contribution toward progress in the field. Such publications, however, have translated to clinical confusion. For example, 

 suggesting that suicide risk assessments are unable to predict who will die by suicide have led to provocative dialogues on whether these approaches should be abandoned, especially given the implied goal that our risk assessment approaches are meant to be predominantly geared toward prediction.

 The predicament of a goal to eradicate suicide along with unrealized ability to accurately predict suicides have cast doubt on the fact that suicide risk assessment and management are actually critical to improving the very care and outcomes current suicide prevention approaches are striving to achieve.

Of course, along with many clinicians, suicide loss survivors, and those with lived experiences, we are invested in finding the answers to prediction. We argue, however, that until that time arrives, and even when it does, we should incorporate assessment and management approaches that are in and of themselves opportunities to collaboratively work with our patients to help them weather suicidal crises and ultimately create a life worth living.

Our therapeutic risk management of the suicidal patient (TRMSP) model is structured to achieve these goals. The TRMSP framework is built on and integrates the tenets of prior research and clinical evidence, the ethical principles of autonomy, nonmaleficence, and beneficence, and medicolegal knowledge and awareness. TRMSP consists of three core components: a clinical interview/suicide risk assessment that is augmented by an evidence-based structured instrument, stratification of risk by severity and temporality, and a collaboratively developed safety plan. In his discussion of the TRMSP model, 

 states that it “provides a way forward and a very nice roadmap not only for better determining level of risk but also for identifying appropriate strategies for intervention and management.”

Every clinician should execute a suicide risk assessment when working with patients who are either at risk for suicide or exhibit warning signs. Listing all the elements to a suicide risk assessment is outside the scope of this article, but the goal behind any risk assessment is analogous to that of an inductive process, that being to gather data about suicide risk indicators, risk and protective factors, and functional patterns to ultimately inform management and intervention approaches in a highly individualized fashion. It is worth stating that the risk assessment is best viewed as an ongoing process, as opposed to an event. Given that the risk assessment process evolves over time, and that there is a potentially endless stream of pertinent and dynamic data to gather, the notion of a complete assessment at any given point in care is rather elusive.

Nonetheless, there are core components that should not be omitted. The addition of a reliable and valid structured instrument to this process is not only medicolegally sound but also affords the opportunity to yield additional information that may be missed during a traditional free-form clinical interview. A more in-depth discussion of considerations when selecting an instrument is provided in 

 Selecting an instrument that attends to critical content, or an element of your clinical interview that is not as robust (eg, protective factors), and enables a quantitative element to your data can be especially helpful. This can enhance disclosure and dialogue between the clinician and patient, which may ultimately shape and guide outcome tracking across management and intervention approaches.

For example, a quantitative measure that helps identify reasons for living (eg, the 

) can be used therapeutically to first help Mr G identify that he does in fact have reasons to keep going and then later to track improvement in this area over time. Similarly, utilizing a measure reflecting the intensity of ideation, intent, and/or desire to die by suicide helps other clinicians (eg, an on-call provider unfamiliar with the patient) recognize changes from the individual’s baseline. Such data help other providers distinguish between modest changes around a chronic baseline versus significant escalations that potentially warrant life-saving interventions, thus facilitating patient-centered, individualized care across both time and clinicians.

As highlighted in the example, clinicians often grapple with the suicide risk formulation for patients similar to Mr. G, that is, those who are chronically suicidal and/or because of demographic and historical factors carry evidence that suggests heightened risk. Forced to choose between commonly used terms such as mild/low, moderate/intermediate, and high, clinicians often experience needless dilemmas. The clinician might worry about documenting high risk and having to explain the decision to not seek involuntary hospitalization. Alternatively, the clinician might feel that the present risk is sufficiently low to not warrant admission, documents low risk, but then worries about having to explain the low-risk designation if an unanticipated suicide attempt occurs. By solely concentrating on severity for these types of patients, a prudent clinician will often land on a formulation of “moderate risk for suicide” given the practicality of all competing factors. This splitting-the-difference approach, however, tends to offer a less nuanced formulation in relation to the nature of the patient’s risk and seldom clearly suggests what needs to be done to mitigate risk in the present and moving forward.

In Mr G’s case, we might decide that he is at high chronic risk and intermediate acute risk for suicide. If we were to slightly change the details of his presentation, to instead reflect that he was experiencing suicidal ideation with some greater frequency, but had an intent of 0, no preparatory behaviors, and no suicide plans, we might then indicate low acute risk for suicide. The critical addition of stratification by temporality allows the clinician to more effectively determine and document what is the best management approach given both acute and chronic considerations. This is the goal of the stratification, ensuring the right management approach, not predicting what will or will not happen in days, weeks, months, or years ahead. Thus, each severity level of acute and chronic risk has associated management considerations. Importantly, decisions surrounding management approaches can be collaborative.

For example, a voluntary psychiatric admission or intensive outpatient management could be appropriate for Mr G. If we know that he had a previous psychiatric admission 5 years ago that was not helpful, and that an admission at this time would complicate his financial and family factors, we might collaboratively discuss a management plan that supports the therapeutic alliance and the opportunity to mitigate risk in an ongoing fashion. Further discussion of risk stratification can be found in 

 We also encourage readers to visit the risk stratification tool we developed at 

https://www.mirecc.va.gov/visn19/trm/#tool

A major component of suicide risk management is safety planning. Before briefly outlining our approach to safety planning, it is critical to note the many pitfalls of the management approach of “no suicide contracts.” These types of contracts, which essentially involve the patient making a commitment to not die by suicide until the next session or that he or she will not enact suicidal behavior without first contacting the clinician, have no evidence base behind their efficacy, afford no medicolegal protection, are not patient-centered, and can have paradoxical effects for both the patient (eg, less disclosure about suicidal desire to not disappoint the clinician) and the clinician (eg, false sense of security which leads to less engagement in appropriate management approaches). In contrast, the safety planning process involves a hierarchical set of strategies designed to help a patient know how to identify and how to cope when in a suicidal crisis.

Especially when done in a collaborative way, safety planning can help the clinician better understand risk and targets for intervention (eg, that the patient is unable to identify warning signs and has limited coping skills) while also providing information about what types of management approaches may be indicated. So, for Mr G, if he is able to develop a sound safety plan that involves many coping strategies and avenues for help, is willing to use the plan over the weekend, and is open to sharing his plan with his wife, intensive outpatient management becomes much more feasible. In contrast, if he is unable to identify how and when his symptoms and distress get worse, has no confidence that he would use coping strategies this weekend, and is unwilling to reach out for professional help if his suicidal intent increased, you would likely need to reconsider how to bolster management approaches as this patient may not be able to independently maintain safety between today’s session and Monday’s check-in call. For a greater discussion on safety planning please see 

Armed with a framework that can optimize the therapeutic benefit of risk assessment, we strongly believe that the real goal of our practice, which is to take care of our patients, can be achieved regardless of the current state of the field. TRMSP is a framework that we have found to be easy to implement, which can ultimately increase the clinician’s comfort and confidence while allowing engagement in work that can be incredibly challenging.

 The three small additions of using reliable and valid structured instruments to augment a suicide risk assessment, enhancing suicide risk formulation by stratifying risk across severity and temporality, and collaboratively developing a safety plan, are essential ingredients to improving care and guiding the path to optimizing outcomes. Finally, while we must recognize the persisting limitations of current risk assessment techniques in relation to prediction of suicide, we must not forget that these same procedures can, and sometimes do, afford life-saving opportunities.

 We encourage readers to visit the risk stratification tool at 

 The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any agency of the US government, agency of the State of Colorado, academic institution, or the institutions and organizations to which the authors are affiliated.

Dr Nazem is Clinical Research Psychologist, Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC), and Assistant Professor, University of Colorado School of Medicine, Departments of Psychiatry and Physical Medicine and Rehabilitation, Aurora, CO; Dr Matarazzo is Director of Clinical Services, Rocky Mountain Regional VA Medical Center, Rocky Mountain MIRECC, and Associate Professor, University of Colorado School of Medicine, Department of Psychiatry, Aurora, CO; Dr Wortzel is Director of Neuropsychiatric Services, Rocky Mountain Regional VA Medical Center, Rocky Mountain MIRECC, Michael K. Cooper Professor of Neurocognitive Disease, Director of Neuropsychiatry, and Associate Professor, University of Colorado School of Medicine, Departments of Psychiatry, Neurology, and Physical Medicine and Rehabilitation, Aurora, CO.

The authors report no conflicts of interest concerning the subject matter of this article.

 Murry D, Devitt P. Suicide risk assessment doesn’t work. Scientific American. March 28, 2017. 

https://www.scientificamerican.com/article/suicide-risk-assessment-doesnt-work/

 Wortzel HS, Nazem S, Bahraini BH, Matarazzo BB. 

Why suicide risk assessment still matters

 Nazem S, Matarazzo B, Wortzel H. Optimizing collaboration and achieving standard of care: a model for therapeutic risk management of the suicidal patient. 

Suicide risk assessment and suicide risk formulation: essential components of the therapeutic risk management model

Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments

 Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. 

Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory

 Wortzel HS, Homaifar B, Matarazzo B, Brenner LA. 

Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality

Therapeutic risk management of the suicidal patient: safety planning

Articles

Determining how to ensure delivery of excellent care while balancing medicolegal demands may seem to be an impossible task. When done in a collaborative way, safety planning can help the clinician better understand risk and targets for intervention.

In the wake of the unfortunate passing of several high-profile individuals, media headlines illustrate a long-standing and persistent challenge regarding how best to speak and write about suicidal self-directed violence. This includes both suicidal thoughts, or suicidal ideation, and behaviors including preparatory behavior, suicide attempt, and death by suicide. Despite the Centers for Disease Control and Prevention advocating for uniform definitions of self-directed violence, coupled with guidelines by leading suicide prevention experts and organizations (eg, American Association of Suicidology, American Foundation for Suicide Prevention) to facilitate understanding and reporting of suicidal self-directed violence in the media, idiosyncratic, even troubling, turns of phrase continue to feature in this context.

The incongruity between recommended reporting guidelines and the language often utilized by the popular press provides evidence of a significant disconnect between the field of mental health and the media. The problem is perpetuated in part by challenges faced within the clinical and research sectors in terms of widespread education and implementation of the preferred suicidal self-directed violence nomenclature. Indeed, a quick online search will produce a litany of headlines featuring what is now considered antiquated language for suicidal self-directed violence, such as an individual who “committed suicide” or experienced a “failed suicide attempt.” Unfortunately, similar language not infrequently still appears in clinical records and communications offered by mental health professionals.

Consequences of biased and negative terminology

Although at surface level these phrases may appear rather benign relative to other outdated terms, such as “suicidal manipulation” or “rational suicide,” these terms, as well as others that are inconsistent with the proposed universal nomenclature, risk maintaining stigma and bias. Illustrative is the Merriam-Webster dictionary definition of “commit,” denoting an action that is deliberate, with “crime” and “sin” being the referent of deliberate action. The use of “commit” (often unintentionally) thus imbues suicide with a sense of badness or moral infirmity. Similarly, a “failed attempt” suggests that dying by suicide equates with success. The use of such biased suicidal self-directed violence terminology may reinforce the negative quality and heighten stigmatization of suicidal thoughts or behavior.

The persistent use of suicidal self-directed violence terminology inconsistent with proffered universal nomenclature carries with it several additional concerns. First and foremost, utilization of nonuniversal suicidal self-directed violence terminology enables, or superficially makes okay, the use of such phrases within clinical, research, and public health settings. Of course, such language is then all the more likely to feature in the popular discourse among the general population. This sets up a cycle of continued use whereby mental health professionals, media, and lay persons mutually influence one another, normalizing terms and phrases that are inherently biased, vague, and at times detrimental to patients’ treatment engagement and recovery.

Suicidal self-directed violence is often a devastating event that touches both the patient as well as those within their social support system including family and friends.

 Lack of patient-centered wording in these circumstances thus has the potential to further exacerbate grieving and complicate the recovery process. For example, headlines reporting on suicidal self-directed violence in a manner that fails to adhere to the current reporting guidelines (eg, “actor uses knife in failed attempt to commit suicide”) not only sensationalizes such events but also has the potential to vilify an individual in crisis as being a “failure” for not “completing” the suicide attempt, or as morally defective for “committing” thoughts or actions involving suicide.

 This likely results in further stigmatization around mental health, and suicidal self-directed violence in particular, which is especially alarming given the significant public health concern that suicide remains.

Toward an appropriate universal nomenclature

Taken in aggregate, the utilization of inconsistent and stigmatizing suicidal self-directed violence nomenclature may represent an additional (and needless) barrier existing among clinicians, researchers, policy makers, and the individuals with whom we are attempting to connect, better understand, and treat. Whereas multiple institutions, including the Departments of Veterans Affairs and Defense, have advocated for, validated, and implemented efforts to promote universal nomenclature around suicidal self-directed violence, to improve provider communication, and decrease inherent bias and stigma, such energies to date have largely been focused on relatively narrow clinical and research communities.

 To the extent that such efforts have gained traction, this mostly has been within large-scale medical settings wherein infrastructure and oversite (a top-down approach) makes feasible the dissemination, mandate of, and oversite needed to realize the use of suicidal self-directed violence nomenclature.

Global use of appropriate suicidal self-directed violence nomenclature requires more than uptake and adherence within medical settings. Attenuation of use of antiquated suicidal self-directed violence terminology requires a multidimensional, multidisciplinary approach that reaches across multiple sectors of the community. Specifically, approaches that continue the public health dialogue among mental health clinicians, researchers, and media personnel are necessary to facilitate consensus. Extant research continues to suggest a significant gap between aspirational language and actual reporting of suicidal self-directed violence, with a 2010 study finding that approximately 36% of reported stories continuing to use repudiated language (eg, commit suicide, failed suicide attempt, suicidal gesture) identified by the recommended media reporting guidelines.

Continued attention to how suicidal self-directed violence is discussed, within both the clinical and media sectors, remains important if we are to understand how nomenclature may influence suicide risk, especially in terms of how biased or stigmatizing language may provoke stigmatizing and dysphoric reactions among patients and those bereaved by suicide. There is some progress: revisions by the 

 in 2015 advocated for discontinued use of the term “commit/committed suicide” in favor of “died by suicide, killed him/herself, took his/her own life,” reflecting a continued culture of change. Further, at the time of this writing, a recent media report described the passing of a celebrity singer due to death by suicide, doing so in accordance with the recommended media reporting guidelines (eg, “singer dies of suicide”). Thus, there remains room for hope, perhaps tentatively even optimism that continued progress toward patient-centered discussion of mental health, including suicide, is achievable. We may even come to collectively utilize a nomenclature that facilitates engagement by patients and compassion more broadly.

Dr Holliday is Advanced Postdoctoral Research Fellow, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, and Instructor, Department of Psychiatry, University of Colorado, Anschutz Medical Campus; Dr Wortzel is Director, Neuropsychiatry Consultation Services, Co-Director, Suicide Risk Management Consultation Program, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, and Associate Professor, Departments of Psychiatry, Neurology, and Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus; Dr Matarazzo is Clinical/Research Psychologist and Director, Clinical Services, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, and Associate Professor, Department of Psychiatry, University of Colorado, Anschutz Medical Campus.

 Crosby AE, Ortega L, Melanson C. Self-directed violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta, GA: Centers for Disease Control and Prevention; 2011.

 Reporting on Suicide. Recommendations for reporting on suicide. 

 Cerel J, Jordan JR, Duberstein PR. The impact of suicide on the family. 

 Department of Veterans Affairs. Memorandum re: standardized suicide nomenclature (Self-Directed Violence Classification System) policy. Washington, D.C.: US Government Printing Office; 2010.

 Office of the Under Secretary of Defense. Standardized suicide nomenclature (Self-Directed Violence Classification System) policy. Washington, DC: US Government Printing Office; 2011.

 Tatum PT, Canetto SS, Slater MD. Suicide coverage in US newspapers following the publication of the media guidelines. 

The Associated Press Stylebook 2015: And Briefing on Media Law

In the wake of the unfortunate passing of several high-profile individuals, media headlines illustrate a challenge regarding how best to speak and write about suicidal self-directed violence.

Hal Wortzel, MD

Articles

Mini Quiz: Suicide Risk Stratification

Suicide Risk Assessment and Management: Tips for Improving Care and Outcomes

Words Matter: The Language of Suicidal Self-Directed Violence