Suicide risk assessment & safety planning

When a client discloses thoughts of suicide, the exam wants to see you do two things well: assess risk systematically and respond with a collaborative safety plan. This is one of the highest-stakes competencies in the field, and it's tested heavily.

Start with the risk factors. Static (unchangeable) factors include a prior suicide attempt — the single strongest predictor — plus family history of suicide, and a history of trauma or abuse. Dynamic (modifiable) factors include current hopelessness (a powerful predictor), depression, substance use, agitation, recent loss, and social isolation. Warning signs are the acute, near-term flags: talking about wanting to die, seeking means, giving away possessions, sudden calm after depression. Access to lethal means — especially firearms — sharply raises risk.

Balance those against protective factors: reasons for living, responsibility to children or pets, social support, religious/moral objections to suicide, engagement in treatment, and problem-solving skills.

Then conduct a structured inquiry. Ask directly — asking about suicide does not plant the idea. Assess ideation, plan, intent, and means (how specific is the plan, how strong the intent, how available the means). Structured tools like the Columbia-Suicide Severity Rating Scale (C-SSRS) guide this inquiry across ideation, plan, and behavior.

Finally, the safety plan. The Stanley & Brown Safety Planning Intervention is the evidence-based standard and has largely replaced the old 'no-suicide contract,' which does not reduce risk. Its six elements, in order: (1) warning signs; (2) internal coping strategies; (3) social contacts/settings that provide distraction; (4) people to ask for help; (5) professionals and agencies to contact, including crisis lines (988); and (6) making the environment safe (means restriction).

Clinical Pearl: A prior attempt is the strongest long-term predictor and hopelessness the key modifiable one — and a collaborative safety plan (Stanley & Brown), not a 'no-harm contract,' is the defensible intervention.