Suicide risk and safety planning

1What CRPO expects

• Competency 4.4: assess for specific risks as indicated, develop safety plans with clients at risk, refer where appropriate, report as the law requires, and follow up to monitor risk over time.
• CRPO's practice manual: risk assessments are structured tools to spot red flags; they are useful but not infallible, and harm can occur when someone is judged low risk.
• Know evidence-based assessment and safety planning tools, document safety planning efforts, and inform clients of risks without steering their decisions.
• A case too complex for your competence is referred or taken to supervision (Standards 1.9 and 2.1).

2Assess: ask directly, then structure

• Asking about suicide does not raise suicidal ideation; talking about it may lower it (Dazzi et al., 2014, Psychol Med 44(16):3361-3363).
• Thoughts, intent, plan, means and access to them, timeframe, past attempts, substance use, and what keeps the person safe: supports, reasons for living.
• Risk factors alone predict poorly: across 50 years of studies, prediction was only slightly better than chance (Franklin et al., 2017, Psychol Bull 143(2):187-232). Use them to understand this person, not to score them.
• While risk is raised, reassess at every contact and say when you will next check in.

3The safety plan, step by step

1. Warning signs: the thoughts, moods or situations that come before a crisis.
2. Coping alone: things the client can do by themselves to get through it.
3. People and places that offer distraction and company.
4. Asking for help: family or friends the client can tell they are struggling.
5. Professionals and services: their therapist, a crisis line, 9-8-8, and 911 or the nearest emergency department.
6. A safer environment: a plan to reduce access to lethal means. Reasons for living can be added.

4Why safety planning

• Written with the client, in their words, and kept by them: Stanley and Brown (2012), Cogn Behav Pract 19(2):256-264.
• With follow-up calls after an emergency visit, 45% fewer suicidal behaviours over six months than usual care, in a cohort comparison (Stanley et al., 2018, JAMA Psychiatry 75(9):894-900).
• A meta-analysis of six studies: relative risk of suicidal behaviour 0.57, with no significant effect on ideation (Nuij et al., 2021, Br J Psychiatry 219(2):419-426).
• Evidence for restricting access to lethal means has strengthened (Zalsman et al., 2016, Lancet Psychiatry 3(7):646-659).

5Involving others

• Plan it together: who may be contacted, and when, goes in the safety plan, so the client's wishes are known before a crisis.
• PHIPA s. 40 (1): you may disclose without consent if you believe on reasonable grounds it is necessary to eliminate or reduce a significant risk of serious bodily harm.
• Weigh the level and nature of the risk, the client's wishes and the options, such as crisis response or police-partnered services (CRPO manual).
• Danger now: call 911. Only a physician applies for a psychiatric assessment (Mental Health Act s. 15); a justice of the peace can order an examination on sworn information (s. 16); police can take a person for examination (s. 17).
• 9-8-8: Suicide Crisis Helpline, call or text 9-8-8, 24 hours a day, every day of the year.

6What to write down

• What you asked and what the client said, in their words where it matters.
• Your judgement of the risk and why, the safety plan and its copy, consultations, referrals and the next follow-up (Standard 5.1).
• Any disclosure without consent: what, to whom, when, why, and under which provision.