Law and Psychiatry Suicide Risk Assessment and Suicide Risk Formulation: Essential Components of the Therapeutic Risk Management Model MORTON M. SILVERMAN, MD

Suicide and other suicidal behaviors are often associated with psychiatric disorders and dysfunctions. Therefore, psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment is a core competency requirement, many clinical psychiatrists lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation sufficient to guide triage and treatment planning. Based on data collected via a suicide risk assessment, a suicide risk formulation is a process whereby the psychiatrist forms a judgment about a patient's foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment planning, and interventions to reduce risk. This paper addresses the components of this process in the context of the model for therapeutic risk management of the suicidal patient developed at the Veterans Integrated Service Network (VISN)

19 Mental Illness Research, Education and Clinical Center by Wortzel et al. (Journal of Psychiatric Practice 2014;20:373–378) KEY WORDS: suicide, suicide risk assessment, core competency, suicide risk formulation

A model for achieving therapeutic risk management of the suicidal patient has been described in the preceding four Law and Psychiatry columns. Dr. Morton Silverman, an international expert in suicidology, now brings his perspective to the model and more broadly addresses the vital issues of suicide risk assessment and suicide risk formulation. He identifies existing gaps in the state of the science and our collective knowledge and offers directions for future research. While there remains much to be learned about how to optimally care for the suicidal patient

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and reduce the risk for self-directed violent behavior, ethical medical practice and cogent risk management mandate that clinicians attend to these issues now. Dr. Silverman discusses how the therapeutic risk management model may help realize this goal. We are grateful for his contribution. Hal S. Wortzel, MD, Law and Psychiatry Editor Mental health care providers have significant opportunities to identify at-risk individuals and engage them in treatment to reduce the risk of suicidal behavior. Suicide risk assessment (SRA) is a core competency that a psychiatrist must possess, informing the treatment and management of all patients.1,2 Psychiatrists are expected not only to foresee the possibility of suicidal behaviors (acute risk) in the near- or short-term (up to 72 hours),3 but also to provide interventions tailored to the specific situation and setting. In the forensic psychiatric literature, a clear distinction is made between predicting suicidal behavior (which is virtually impossible to do with any accuracy) and foreseeing the possibility of suicidal behavior in the near- or short-term. Foreseeing the possibility of suicidal behavior is dependent upon the appropriate assessment of suicidal risk. The standard of care requires psychiatrists to make diagnoses and offer treatments that have been shown to be effective. However, many psychiatrists lack the requisite training and skills to appropriately assess for suicide risk.4 In addition, current risk assessment practices remain highly variable across providers. It should not be surprising, then, that patients who have died by suicide were more likely to have been formulated to be at low risk when last assessed before their deaths.5 Dr. Silverman is the Senior Science Advisor to the Suicide Prevention Resource Center in Waltham, MA. He is a Clinical Assistant Professor of Psychiatry at The University of Colorado. Address correspondence to: [email protected] DOI: 10.1097/01.pra.0000454784.90353.bf

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Law and Psychiatry STANDARD OF CARE The standard of care in working with patients at risk for suicide requires that the clinician first assess the patient’s relative risk, based on an SRA. However, there appears to be confusion about what is meant by an SRA. Many papers in the literature use the term “suicide risk assessment” as an all-encompassing term for a process that includes risk assessment, risk formulation, determination of level of risk, and identification of appropriate interventions. This is confusing because many clinicians understand an SRA to simply involve assessing risk for suicide based on obtaining a standard history and performing a mental status examination. Unfortunately, all too often, such an assessment ends when a patient gives a negative response to the question, “Are you thinking about killing yourself today?” An SRA that ends after a patient denies current suicidal ideation is an inadequate assessment.6 No methods for conducting an SRA or developing a suicide risk formulation (SRF) have been empirically tested for reliability and validity or have sufficient sensitivity and specificity to be effective in predicting actual suicidal behavior.7,8 However, the standard of care requires mental health professionals to recognize and foresee the possibility that a patient might engage in suicidal behavior, hence to conduct an SRA and make an SRF sufficient to guide triage and treatment planning. Clinicians need a better protocol that they can use to assign level of suicide risk to an individual. Without such a guide, clinicians must rely on their education, training, intuition, judgment, and prior experience to determine how best to intervene and manage a potentially suicidal patient. Although clinical judgment and intuition are, of course, influenced by knowledge and experience, greater experience does not necessarily result in better judgment or improved competence, which can only develop with extensive deliberate practice and corrective feedback.9–12 There is no doubt that sound clinical judgment must be brought to the task of risk formulation, but the question of whether clinicians can be trained in a way that will improve their clinical judgment has yet to be answered. Moreover, despite its obvious appeal, it is dangerous and unpredictable to rely on “clinical intuition” in judging the risk level for an individual, especially when life or death hangs in the balance. However,

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actuarial models for predicting a patient’s risk of violence, in contrast to clinical judgment, may also not be superior.13 Consequently there is a need to bring as much science into this process as possible in order to arrive at the best possible approach to risk formulation. And there is evidence that this is possible.14

SUICIDE RISK ASSESSMENT AND SUICIDE RISK FORMULATION One of the main goals of any clinical interaction is to diagnose why the patient is in pain and to provide relief through the best available, culturally sensitive, and appropriate interventions that address the individual’s specific issues. In order to achieve this outcome, the clinician must gather data and filter those data to arrive at an intervention. We see this as a two-part process: first, determining whether an individual has factors associated with increased risk for suicide and, second, formulating the level of risk.15 These steps then inform appropriate triage decisions, safety and treatment plans, and interventions (ideally evidence-based) to reduce the level of risk for that specific individual in that setting. Suicide Risk Assessment An SRA gathers data about observable and reported symptoms, behaviors, and historical factors presented by a patient that are associated with suicide risk and protection, ascertained by way of psychiatric interview and collateral information from family, friends, medical records, psychometric scales, and/or screening tools. As Simon noted,6 “Risk and protective factors must be pulled together into the process of analysis and synthesis. Suicide risk assessment allows the clinician to piece together (identify and prioritize) risk and protective factors to construct a clinical mosaic (synthesis) of the suicidal patient.” Existing SRA protocols offer little to no guidance on how to organize, integrate, conceptualize, or prioritize the data obtained (i.e., to derive a risk formulation and determine a level of risk). Some offer checklists and/or scales (Likert scales) for each item believed to be essential in conducting an SRA, but there are no formulas that translate these individual risk factor ratings into an overall formulation of level of risk.16 I believe that the literature on SRA does not adequately address the critical role of SRF, and it rarely discusses the techniques, tools, approaches,

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Law and Psychiatry and concepts involved in formulating the level of suicide risk based on the data acquired during the SRA. Collecting SRA data is important; it is a necessary step in determining how to provide the appropriate treatment for the individual. But determining the appropriate interventions for the suicidal patient requires the additional steps involved in formulating and determining the level of the suicide risk. Suicide Risk Formulation An SRF is a process by which the clinician forms a judgment about a patient’s foreseeable risk of suicidal behavior based on data collected via an SRA.17 A formulation involves some understanding of how risk factors combine, interact, exacerbate, or otherwise contribute to a “recipe” for heightened risk for suicidal behavior, in both the short- and long-term. Moreover, the formulation of level of suicide risk requires clinical acumen, experience, and judgment. The SRA, therefore, is a precursor to an SRF, and the reliability and validity of the SRF is dependent on the robustness of the SRA.5 Impressive gains have been made in identifying lifetime, or long-term, risk and protective factors for suicidal behavior. However, one of the most important responsibilities of clinicians is to determine who is at near-term, or acute, risk for suicidal behavior. Yet despite decades of research devoted to the study of risk and protective factors for suicide and suicidal behavior, surprisingly little is known about nearterm risk factors for these behaviors.18 Accordingly, no empirically supported method currently exists for incorporating objective markers of near-term risk in a way that can inform our determination of an individual’s risk for future suicidal behavior (i.e., low, moderate, high, or acute risk). In the absence of a tool for synthesizing this information, clinical judgment or intuition is currently used, rather than science, to combine details about risk and protective factors and warning signs. Very few empirical studies of the short- and longterm outcomes of those patients who were labeled as low, moderate or high risk have been done. Many studies only conduct a follow-up with those who have been hospitalized for a “medically serious suicide attempt.”19 The assumption is that a medically serious suicide attempt indicates that the patient was at high, imminent, acute, or immediate risk. There have been virtually no empirical studies that link treat-

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ments or interventions with specific levels of risk. Hence we really don’t know much about what treatments work best or are most effective or cost-efficient for low versus moderate versus high-risk individuals. What is needed are prospective studies aimed at identifying novel, near-term predictors, examining methods of synthesizing this information, matching interventions with level of risk, and testing the ability to predict and prevent suicidal events. This risk assessment, risk formulation, and risk management process ideally should occur within a therapeutic relationship, all the while recognizing the reality that we function in clinical settings that are often governed by medico-legal principles and practices.20

THERAPEUTIC RISK MANAGEMENT Simon and Shuman introduced the concept of therapeutic risk management of clinical-legal dilemmas in 2009.21 This concept “assumes that, in addition to clinical competence, there is an optimal therapeutic accord to be found in each case which demands a working knowledge of the law regulating the practice of psychiatry” (p. 155). Their focus was on the successful resolution of clinical-legal dilemmas, which “requires an understanding of the legal process that helps clinicians to provide good patient care and to avoid unnecessary and counterproductive defensive practices” (p. 155). Hence, therapeutic risk management is based on clinical risk management that is patient-centered, supportive of the treatment process, and maintains the therapeutic alliance. Simon and Shuman emphasized that the therapeutic risk management of the suicidal patient is highly nuanced, with various clinical situations and treatment settings mandating specific considerations; therapeutic risk management is necessarily tailored to both the individual and the treatment environment. In a companion piece, Frierson and Campbell22 discussed how the principles of the therapeutic risk management model of suicidal patients can be integrated into each of the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME) for psychiatric residents.23 However they stated that, “While the model we have outlined represents a platform for the teaching of therapeutic risk management in suicidal patients, it does not constitute a comprehensive list of what may be needed within each individual competency” (p. 167).

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Law and Psychiatry THE VISN 19 MIRECC THERAPEUTIC RISK MANAGEMENT MODEL

A PRACTICAL APPROACH: TAKING STEPS TO WORK BACKWARDS

The therapeutic risk management model developed by Wortzel et al.24–27 at the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC) 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. This model for therapeutic risk management of the suicidal patient involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. The combined clinical evaluation and structured risk assessment process guides estimates regarding the patient’s level of risk for suicide. Estimates regarding the level of risk should then dictate clinical decision-making, particularly as it pertains to the appropriate treatment setting and the level of care required. Traditionally, level of risk has been stratified according to severity, using modifiers such as low, medium or intermediate, and high. As Wortzel et al. point out, this one-dimensional stratification system, which lacks any temporal referent, is inadequate for accurately labeling risk and guiding clinical decision-making. The VISN 19 MIRECC therapeutic risk management model proposes a two-dimensional risk stratification that accounts for both severity and temporality (e.g., low acute risk; high chronic risk) that more accurately depicts the individual’s actual risk for suicide and better facilitates clinical decisionmaking (e.g., that the patient is safe and appropriate for outpatient care but needs to have a safety plan in place in anticipation of future suicidal crises). Unlike a safety contract, which seeks promises from a person in severe emotional turmoil, the safety plan offers six concrete steps in which the individual can actively engage, in order to safely navigate a suicidal crisis.28 The process of building a safety plan is a collaborative one, thereby facilitating the therapeutic alliance, culminating in a concrete and individualized plan for action when confronted with future suicidal thoughs and behaviors, yielding a living document for the medical record that serves both clinical and medico-legal purposes, and thereby truly embodies the process of therapeutic risk management.

While the standard of care for clinical interactions with suicidal individuals includes a thorough clinical evaluation, determination of foreseeable risk of selfinjury, and the provision of reasonable interventions appropriate to that encounter, a roadmap and a clear set of directions do not exist. One way to think about achieving this goal is to “work backwards,” utilizing the VISN 19 MIRECC therapeutic risk management model as outlined by Wortzel et al. in prior columns in this journal.24–27 I suggest that the desired outcome of the clinical encounter is to engage in a therapeutic intervention that will acknowledge and assess risk factors, protective factors, precipitating events, and warning signs, and address them by developing and implementing a safety plan, as well as monitoring and managing suicide risk. Hence the conceptual approach is to work toward that “end point” at each step of the risk assessment and risk formulation.

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1. Thoughtfully combine structured assessments and measures to facilitate the identification of both contemporaneous levels and historical aspects of suicide risk, as well as to identify often neglected protective factors that will need to be optimized to mitigate chronic levels of risk.25 Since suicidal ideation, intent, and planning may be very difficult for some patients to disclose, the inclusion of structured assessment tools, including self-report measures, provides another potential avenue and opportunity for detecting thoughts of suicide. In my opinion nothing replaces a well-conducted clinical SRA. However, from a medico-legal perspective, there is no agreement on a standardized SRA. Hence the addition of objective, structured assessment techniques and tools can provide support and corroboration for a well-conducted clinical SRA. It is important to note that Simon has admonished clinicians not to rely solely on forms in conducting a suicide risk assessment.16 Similarly, in their series on therapeutic risk management, Worzel et al. dissuaded providers from over-reliance on quantitative indicators of risk.25 It is, of course, possible to miss suicidal ideation when using clinical SRA, self-report measures, or structured tools. But combining methods of assessment increases opportunities for captur-

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Law and Psychiatry ing information of vital importance to achieving an accurate SRA. 2. Stratify risk in terms of both severity and temporality, rather than simply assigning a single level of risk.26 Level of risk determinations are not standardized or defined. I have seen various systems that range anywhere from 3 “determinations” (low, moderate, high) to 6 or more (e.g., very low, low, moderate, high, very high, acute, imminent), and systems that use combinations and permutations of these qualifiers. 3. Develop (through collaborative engagement) and document a safety plan that is based on the specifics of the patient’s presentation.27,28 There is no agreed-on set of interventions for each designated level of risk. Many schemas exist, but they do not agree on the classification categories or what interventions are recommended for each of these levels of risk. However, the safety plan intervention offers six concrete steps in which the individual can actively engage in order to safely navigate a suicidal crisis.

CONCLUSION No longer is it sufficient just to make a diagnosis and offer a treatment regimen. Risk management is a reality of psychiatric practice, and this necessitates practicing (and documenting) thoughtful suicide risk assessment, suicide risk formulation, intervention, and short- and long-term management. We need a stepwise approach toward assessment, formulation, determination of level of risk, and assignment of appropriate and proven interventions based on the level of risk. We need to refine our approach to include all the elements that comprise the assessment and management of suicidal patients. We also need to better use anchors for arriving at a determination of suicide risk. Acquiring the skills of SRA and SRF often comes through appropriate supervision, numerous clinical interactions, and experience. However, not everyone has had the advantage of being exposed to numerous presentations of suicidal individuals and having opportunities to assess these individuals and receive the supervision necessary to help formulate a level of risk and select an appropriate intervention that best matches the level of risk and the patient’s unique clinical issues. A few professional and governmental

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organizations have developed formal training programs for the assessment and management of suicidal individuals. These programs, which usually involve 1- or 2-day training sessions,29,30 have not been attended by many psychiatrists. Inasmuch as clinicians are potentially held accountable through tort actions when, and if, a patient in treatment dies by suicide, improving the clinical judgments involved in clinical decision-making regarding the assessment, triage, treatment, and management of these patients has significant implications. The failure to reasonably accomplish these tasks has the potential for significant negative outcomes for both the patient (a possible preventable death by suicide) and the clinician (the premature death of a patient; a preventable tort action). Through the introduction of the VISN 19 MIRECC therapeutic risk management model, Wortzel et al.24–27 have provided us with some specific operational tools and techniques both for the current psychiatric resident trainee as well as for practicing psychiatrists who were trained before the introduction of the ACGME core competencies. Wortzel et al. have outlined a sequence of events and approaches to developing the requisite database that is needed to formulate a level of risk and provide an appropriate intervention. This model involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. This VISN 19 MIRECC therapeutic risk management model has the potential to improve our assessment and management of suicidal individuals by collectively yielding a suicide risk assessment and management process (and attendant documentation). It should also withstand the scrutiny that may occur in the wake of a patient suicide or suicide attempt.

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

Suicide and other suicidal behaviors are often associated with psychiatric disorders and dysfunctions. Therefore, psychiatrists have significant oppor...
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