A multidisciplinary approach to therapeutic risk management of the suicidal patient

Figures & data

Figure 1 Multidisciplinary use of TRMSP.

Abbreviations: ED, emergency department; TRMSP, therapeutic risk management of the suicidal patient.

Table 1 Stratified suicide risk assessment

Temporality
Acute	Chronic
Severity
High
Suicidal ideation with intent to die by suicide Inability to maintain safety independent of external supports or help	Recurring or chronic suicidal ideation May have a history of suicide attempt(s)
	Limited coping skills related to unpredictable, situational stressors Limited ability to identify reasons for living
	Presence of addition risk factors such as chronic severe mental illness and/or personality disorder, substance abuse, chronic pain, unstable or turbulent psychosocial status
Intermediate
Suicidal ideation	Similar risk factors present as above with recurring suicidal ideation
Patient perceives his or her ability to maintain safety independent of external support or help	Presence of protective factors, such as coping skills, reasons for living, and relative psychosocial stability suggesting the ability to endure crises without engaging in suicidal behaviors
May or may not have intent to die by suicide
Patient should be able to follow a safety plan
Low
No current suicidal intent  No plan for suicide	Broad category that may include patient with significant mental health or substance abuse issues, but who maintain good coping skills and strengths; category may also include patient with few mental health problems
No preparatory behaviors	Ability to endure stressors with little or no suicidal ideation
Confidence (by provider, patient, family, etc) in the ability of the patient to independently maintain safety	Patient typically has no history of self-directed violence, lacks impulsive or risky behavior, does not have severe or persistent mental illness; stable psychosocial functioning is likely present

Note: Data from Wortzel et al.⁵

Table 2 Safety planning intervention

SPI steps	Rationale	Application
Introduction of the plan	Explain rationale for developing a safety plan to the patient	Provider conveys compassionate interest in helping the patient cope with suicidal thoughts
Step 1: Warning signs	Identify person-specific suicide warning signs in the patient’s own words	Provider advises patient to use the next steps in the safety plan when he or she recognizes warning signs
Step 2: Internal coping strategies	Patient lists coping strategies that can be used to distract him/her from the suicide crisis without the help of another person	Provider can prompt patient to identity strategies that have worked in the past Provider should ensure that coping strategies are individualized and specific
Step 3: People and social settings that provide distraction	Patient lists individuals who he or she can reach out to for the purpose of distracting from the suicide crisis	Provider encourages patient to increase his or her social connection
Step 4: People whom I can ask for help	Patient identifies who he or she can contact and be notified of crisis	Provider and patient agree on personal contacts whom the patient can reach out to engage in help- seeking behaviors
Step 5: Professionals and agencies I can contact during a crisis	Patient identifies professionals and emergency resources that he or she can contact in the event that previous steps do not resolve the suicide crisis	Provider should discuss what to expect when patient contacts these resources (eg, conditions that may warrant emergency mental health intervention)
Step 6: Making the environment safe	Patient should remove or restrict access to weapon or other lethal means in his or her environment	Provider can offer gun locks to secure weapons or medication drop off information to dispose of excess medication Provider should help patient identify reminders of reasons for living that can be emphasized in the home (eg, pictures of family members posted on the refrigerator)

Abbreviation: SPI, safety planning intervention.

WortzelHSHomaifarBMatarazzoBBrennerLTherapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporalityJ Psychiatr Pract2014201636724419312

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