Formulating Risk Status for a Suicide Assessment

In the first post of this series, I introduced a Framework to Guide Suicide Assessment based on the Four Core Principles used by 988 centers nationwide. In Part Two, I then explored how to gather information 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 the final part of the series, I will focus on how we use the information gathered to formulate risk and 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 sufficiently detailed clinical assessment that allows the client to tell their story and lets you 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; 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 is the plan.

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 that). So, we label the risk. But in practical terms, how useful is it?¹

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 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 risk over time. Most importantly, it does not guide us in what actions to take to ensure safety. So, let's say my client meets some established criteria for a 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 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. Given this, they may meet established criteria for being at high risk for suicide. But what if your client frequently presents this way but also denies 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 a 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 that exists and do nothing to guide the intervention and care. [Adapted from Wortzel 2014].

One model that I find useful in practice,² which incorporates both a two-tiered system and focuses on actions to take, is the Therapeutic Risk Management Risk Stratification Table (US Dept Veterans Affairs, 2024). 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.³ (If you view the table in the link above, you can see how actions to take are aligned with available systems within the context of where the assessment occurs.)

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Adaptations of this have been developed for a range of settings. In training clinicians, I encourage them to modify this model to incorporate actions they may consider in their own practice.

As an example, the way I have adapted this model for my practice is grounded in the Four Core Principles of Suicide Assessment discussed in Part One and I outline possible client presentations with actions I could consider for high, moderate, and low-risk scenarios across acute and chronic timeframes.

In terms of HIGH ACUTE RISK, for example, COLUMN 1 may look as follows:

COLUMN 1:

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 address lethal means

Assessment Presentation

Likely express thoughts of suicide and have a plan

Capability enhanced by having a history of attempts in addition to access to means

Likely unable to establish a safe environment

May be experiencing acute psychosocial stressors

May be highly dysregulated with no real coping skills

Then in the column next to it, I outline actions I could consider to maintain safety. Individuals in this category (high acute risk) typically require hospitalization, though this would only be considered after all other options have been exhausted. [NOTE: For most other categories the actions to consider would involve safety plan development and addressing access to lethal means in addition to suicide-focused care.]

COLUMN 2:

Actions to Consider to Maintain Safety

Client agrees with need for hospitalization:

Contact 911

Inform clients emergency contact

Request ER location

Contact ER and provide assessment

Follow-Up with client and/or emergency contact

Client does not agree and/or leaves the office:

Contact client's emergency contact

Make MCT referral (call 988)

Other (note below—specific to your practice)

In the adapted version 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 (I also have a more detailed protocol for hospitalization process). 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 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)