While the practice of psychiatry involves many challenges, few scenarios are as clinically and emotionally demanding as managing the patient who is at high risk for suicide. Much of the challenge of course relates directly to caring for an individual in severe emotional distress and genuinely wanting to reduce suffering while keeping that person safe from harm; we worry about these patients. Part of the challenge derives from the fact that optimal management of a suicidal patient forces us to make tough choices, selecting between two of our highest-ranking guiding ethical principles, autonomy and beneficence.1
Typically, we respect the right to self-determination, allowing our patients to make informed choices for themselves. But sometimes beneficence, doing what is ultimately in the best interest of the patient, will mandate making decisions to optimize patient safety that are contrary to the individual’s wishes. For instance, the choice to involuntarily hospitalize a patient who is judged to be at high acute risk for suicide is not without consequences; therapeutic relationships and progress toward long-term treatment goals may be disrupted by a psychiatric admission, particularly one that is unwanted. Death by suicide remains a relatively infrequent event, and efforts to avoid unnecessary and potentially disruptive involuntary admissions are a necessary component of competent psychiatric practice. However, the consequences of failing to act in the face of a genuine suicidal crisis are potentially catastrophic, possibly culminating in a death by suicide and all that may come in its aftermath. Navigating these clinical dilemmas can be both emotionally taxing and medicolegally disconcerting.
While the likelihood of encountering patients at high risk for suicide will vary to some degree among clinical settings, all mental health professionals need to be attuned to suicide risk, and competent at risk assessment and management. A survey of psychiatric consultants conducted by Alexander et al.2 revealed that 67% of respondents had experienced having a patient under their care die by suicide, and 33% reported that these patients’ deaths impacted their personal lives, involving experiences such as irritability at home, being less able to deal with routine family problems, poor sleep, low mood and anhedonia, preoccupation with suicide, and decreased self-confidence. Adding to the consternation associated with suicides and suicide attempts is the specter of litigation. Suicides and suicide attempts were one of the leading sources of malpractice claims against psychiatrists during the years 2000–2009, accounting for 17% of such litigation.3 We need to be assessing and managing suicide risk not only to take good care of our patients, but also to take good care of ourselves.
Risk management is a reality of psychiatric practice, and this necessitates practicing (and documenting) thoughtful suicide risk assessment and management. The Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC) has developed a multidisciplinary suicide consultation service, offering consultations to mental health professionals serving Veterans thought to be at high risk for suicide. The service spans a number of treatment settings, such as outpatient mental health clinics, inpatient psychiatric units, residential posttraumatic stress disorder treatment programs, substance use disorder clinics, and primary care-based behavioral health services. The service has evolved over half a decade to accommodate the needs of Veterans and providers in these various treatment settings while employing medicolegally informed clinical and documentation practices to realize what Simon and Shuman have termed “therapeutic risk management.”4 In this article, we present a broad overview of the model that has evolved, starting with a review of the concept of therapeutic risk management, and then briefly discussing core aspects of our risk assessment and management consultation process including augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. Subsequent articles in this series will elaborate on each of these three chief components. These elements are readily accessible to and deployable by mental health clinicians in most disciplines and treatment settings, and they collectively yield a suicide risk assessment and management process (and attendant documentation) that should withstand the scrutiny that often occurs in the wake of a patient suicide or suicide attempt.
Therapeutic Risk Management
Therapeutic risk management affirms the clinician’s role in the treatment of the suicidal patient. It requires a working knowledge of the legal regulation of psychiatry to inform appropriate clinical management of legal concerns that frequently arise regarding suicidal patients in crisis… Therapeutic risk management is an essential part of good clinical care. It supports the patient’s treatment and the therapeutic alliance. The pervasive ethic is beneficence and, “First do no harm.” Therapeutic risk management avoids defensive practices of dubious benefit that, paradoxically, can invite a malpractice suit. Moreover, an unduly defensive mindset can distract the clinician from providing good patient care.4 (p.157)
Clinician anxiety over the potential for litigation can result in defensive practices that are counter- productive at many levels. For example, unnecessary involuntary hospitalization of a patient for suicide risk may severely damage the therapeutic relationship, the very relationship that may prove vital to mitigating risk on a longer timeline. Similarly, the disruptive impact of a hospitalization may result in psychosocial setbacks in other areas of the individual’s life, such as employment or interpersonal relationships, again having a potentially adverse impact on important protective factors and the equation surrounding chronic or long-term risk for suicide. An unnecessary hospitalization and the resulting curtailment of patient autonomy may even result in legal action against the provider, resulting in the very sort of litigation and scrutiny that was driving the defensive practice in the first place. Of course, hospitalization is a necessary and appropriate part of managing the patient at high acute risk for suicide, but the decision to admit needs to be based on clinical realities and decision-making that are unencumbered by provider anxiety and are not driven by defensive motives.
Fortunately, the best way to take good care of our potentially suicidal patients and ourselves is one and the same—to practice clinical risk management that is patient-centered, supportive of the treatment process, and maintains the therapeutic alliance. At the end of the day, the provision of good clinical care that is appropriately documented yields the best risk management. Clinicians need to understand that the law does not require best practices or the ability to predict suicide to escape liability in the event of a suicide or suicide attempt. Well reasoned therapeutic risk management procedures should exceed the requisite standard of care, whether the jurisdiction defines that as customary practice or the practice of the reasonable, prudent practitioner.
Needless to say, 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. Simon offers a variety of setting-specific considerations spanning outpatient treatment, collaborative care arrangements, inpatient treatment, and emergency psychiatric services—clinicians are encouraged to familiarize themselves with the recommendations applicable to their practice setting.3 The model overview that follows represents select elements inspired by the concept of therapeutic risk management that our consultation service employs across treatment settings.
Augmenting Clinical Risk Assessment with Structured Instruments
Just as a combination of clinical and structured assessment techniques improves the assessment of violence risk, such a combination may also benefit assessment of suicide risk. While a thorough clinical evaluation remains the standard of care in suicide risk assessment, unstructured clinical examinations (free-form clinical interviews) may miss important aspects of risk or protective factors. That potential may be minimized by augmenting the clinical examination with more structured assessment tools. Structured assessments/measures can be thoughtfully combined to facilitate the identification of both contemporaneous levels of suicidality and historical aspects of suicide risk, as well as to identify the often neglected protective factors that will need to be optimized to mitigate chronic levels of risk. In addition, since suicidality 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. Of course, the results of these structured assessment tools can then be placed in the patient’s record, supporting clinical care by enabling the clinician to track suicidality over time, and serving a medicolegal function by documenting a thoughtful and multifaceted approach to risk assessment (when combined with a thorough clinical evaluation). The selection and utilization of specific structured assessments will be reviewed in a subsequent article in this series. For now, readers can begin to explore some assessment options at the VISN 19 MIRECC website (www.mirecc.va.gov/visn19/research/assessment_tools.asp).
Stratifying Risk in Terms of Both Severity and Temporality
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 level of care required (e.g., ongoing management on an outpatient basis versus the need for inpatient admission). Traditionally, level of risk has been stratified according to severity using modifiers such as low, medium or intermediate, and high. In our clinical experience, this one-dimensional stratification system, lacking in any temporal referent, is inadequate for accurately labeling risk and guiding clinical decision-making. Take for example the hypothetical patient with borderline personality disorder, substance abuse, intermittent homelessness, and multiple prior suicide attempts. A given presentation involving current sobriety, reasonably stable housing, medication adherence, and chronic suicidal ideation at levels slightly below baseline may portend little in the way of acute risk for suicide. Simultaneously, such an individual faces a chronic risk of becoming acutely suicidal in the face of inevitable future psychosocial stressors. A two-dimensional (accounting for severity and temporality) risk stratification that identifies low acute risk with high chronic risk more accurately depicts the individual’s actual risk for suicide and better facilitates clinical decision-making (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). It also eliminates the double-edged sword of choosing between discharging a “high-risk” patient or having to explain erroneous “low-risk” designation if or when that individual goes on to engage in self-directed violent behavior in the weeks or months ahead. An expanded discussion of this two-dimensional risk stratification system will be the subject of a future article in this series.
Developing and Documenting a Safety Plan
Suicide prevention contracts or “no-harm” agreements remain in widespread use despite little evidence supporting this practice. Not only is there little reason to believe that “contracting for safety” actually reduces suicide risk, but the practice may actually increase risk in certain situations.5 The clinician may gain a false sense of security based on unsound assurances, let down his or her guard, and thus may forgo the necessary risk assessment process, or fail to implement appropriate interventions (e.g., means restriction). These contracts are particularly inappropriate in a clinical setting where little (if any) meaningful therapeutic relationship exists between patient and provider; it is unreasonable to expect that a person in the midst of a suicidal crisis will avoid self-directed violent behaviors because he or she made an assurance to a provider met only moments ago in an emergency department.
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 safety navigate a suicidal crisis. 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 suicidality, yielding a living document for the medical record that serves both clinical and medicolegal purposes, and thereby truly embodies the process of therapeutic risk management. Safety planning will be the topic of a future column, but readers can learn more about the process now online (http://www.mentalhealth.va.gov/docs/VA_Safety_planning_manual.pdf).6
This introduction to the VISN 19 MIRECC model for therapeutic risk management of the suicidal patient is intended to provide readers with a broad overview of a process that enhances suicide risk assessment and management. Optimization is realized clinically and medicolegally, for both patients and providers, by implementing the use of a few relatively simple and accessible tools and/or concepts that can be deployed across numerous clinical settings and by providers from various mental health disciplines. Future columns will provide more indepth information on augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan.