Description
This document provides a detailed clinical and legal framework for conducting and documenting a suicide risk assessment. Written by senior clinical staff from the California Department of Corrections and Rehabilitation, it focuses on the critical need for clinicians to produce a well-reasoned written justification of suicide risk, emphasizing thorough documentation over definitive prediction. The article outlines the CAIPS mnemonic as a practical guide, which covers Chronic and Acute risk factors, Imminent warning signs, Protective factors, and a final Summary statement. It includes practical strategies such as explicitly addressing hopelessness, using patient quotes, consulting with colleagues, and resolving discrepancies between patient statements and behaviors. Aimed at practicing psychiatrists, psychologists, and social workers, this resource is essential for enhancing clinical decision-making, ensuring legal defensibility in high-stakes scenarios, and developing prudent treatment plans. It serves as a vital guide for mental health professionals seeking to standardize and strengthen their assessment processes. Review this structured methodology to improve the rigor and clarity of your clinical documentation.
What's inside
Current Psychiatry March 2015 Pearls S uicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid ance on how to write a clinically sound, legally defensible SRA. The crux of every SRA is written justifica tion of suicide risk. That justification should reveal your thinking and present a well- reasoned basis for your decision. Reasoned vs right It’s more important to provide a justifica tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill- considered. You need to craft a logical argu ment, be clear, and avoid jargon. Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case. C hronic and A cute factors. Address the chronic and acute factors that weigh heavi est in your mind. Chronic factors are condi tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else where, such as on a checklist. I mminent warning signs for suicide. Address warning signs (Table 1),1 the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument. Dr. Obegi is Senior Psychologist Supervisor, Drs. Rankin and Williams are Senior Psychologist Specialists, and Ms. Ninivaggio is Senior Social Worker Supervisor, California State Prison, Solano, California Department of Corrections and Rehabilitation, Vacaville, California. Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products. How to write a suicide risk assessment that’s clinically sound and legally defensible Joseph H. Obegi, PsyD, Jeffrey M. Rankin, DMH, J. Craig Williams, Jr, PsyD, and Gena Ninivaggio, LCSW Table 2 The nature of suicidal ideation Access to means Active intent Lethality of means Method Onset, frequency, intensity, duration, precipitants Plans Proximity of help Rehearsal Specific thoughts Wishes to die Table 1 Imminent warning signs of suicide: IS PATH WARM I Suicidal Ideation S Increased Substance abuse P Purposelessness A Anxiety, agitation, sleep disturbance T Feeling Trapped H Hopelessness W Withdrawal A Anger R Recklessness M Mood changes Source: Adapted from Reference 1 Current Psychiatry Vol. 14, No. 3 P rotective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter. S ummary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method. Additional tips Consider these strategies: • Bolster your argument by explicitly addressing hopelessness (the strongest psy chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega tives to show completeness2 (ie, “denied sui cide plans”). • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday). • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg ment. A clear and reasoned justification will reduce …
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