Relational Suicide Assessment: Risks, Resources, and Possibilities for Safety

Identify significant others who could assist in implementing relevant details of the safety plan.
II. Work out how to prevent and/or restrict access to means for making a suicide attempt.
III. Explore reasonable alternatives to troubling behaviors for coping with distress.
IV. Identify safe havens the client could, if necessary, access for a limited time.
V. Consider the possibility of the client’s taking a leave of absence from work and/or school.
VI. Determine if the client would consider initiating, resuming, or continuing psychotherapeutic and/or medical treatment.
VII. Generate a list of personal resources the client could contact if necessary.
VIII. Identify emergency resources the client could access if necessary.

. Coming to a Safety Decision
According to the American Psychiatric Association (2003), “the estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment” (p. 24). From our perspective, clinical judgment is quintessentially a decision about the client’s safety that takes shape, often gradually and seldom linearly, over the course of a suicide assessment, informed by an empathic grasp of the client’s intra- and interpersonal risks and resources. In order to come to a decision about the client’s potential for staying safe over the coming days, you must continually juxtapose different sources of information throughout the session:
• Your empathic grasp of the client’s intrapersonal and interpersonal risks and resources.
• Your perceptions of the client’s engagement with you in the assessment process, including his or her response to your empathic comments, to your questions, to your therapeutic suggestions (both direct and implicit), and to the development and possible implementation of the safety plan (see Step 3, below).
• Your insider (empathic) and outsider (professional) sense of whether the safety plan feels safe.
For reasons outlined earlier, we don’t believe it makes sense to try to metaphorically “weigh” or quantify these data as a means for decision-making. Instead, we again turn to qualitative researchers for inspiration. They analyze their data by juxtaposing information from various sources, allowing understanding to “emerge” from the ongoing comparisons. There is an appreciation in this process not only of analytical (outsider or professional) understanding, but

Some of the more commonly accepted risk factors include hopelessness10; previous threats and attempts11; mood and emotional problems and instability, including depression,12 bipolar disorder,13 posttraumatic stress disorder (PTSD),14 panic,15 and anxiety16; self-harming behaviors17; intensive psychiatric involvement18 and psychiatric hospitalization19; substance abuse20; psychotic symptoms (including hallucinations and delusions)21; a family history of suicide attempts22; neuropsychological dysfunction23; access to firearms24; recent losses25; sleep disturbances, including nightmares26; a history of physical and/or sexual abuse27; sexual orientation28; chronic pain29 and medical conditions30; unwanted pregnancy31; and stress related to school,32 work,33 and legal entanglements.34