Risk Assessment and Safety Planning

What Is a Clinical Risk Assessment?

A risk assessment is a structured clinical evaluation of a client’s potential for self-harm, suicide, or harm to others. It is not a one-time event but an ongoing process that should be documented at intake, during acute episodes, and at treatment termination.

Key Components

Suicidal Ideation Screening

Use validated instruments to structure your assessment:

• Columbia Suicide Severity Rating Scale (C-SSRS): Distinguishes between passive ideation (“I wish I were dead”) and active ideation with intent and plan. Widely recommended as a clinical standard
• PHQ-9 Item 9: Screens for self-harm thoughts as part of routine depression monitoring. A score increase on this item warrants expanded assessment regardless of total score trajectory

Risk Factors to Assess

• Static factors: Previous suicide attempts, family history, demographic risk factors, history of trauma
• Dynamic factors: Current stressors, substance use, hopelessness, social isolation, access to means, recent losses
• Protective factors: Social support, reasons for living, engagement in treatment, future orientation

Imminent vs Non-Imminent Risk

• Imminent risk: Active suicidal ideation with intent, plan, and access to means. Requires immediate intervention (crisis services, hospitalisation, means restriction)
• Non-imminent but elevated risk: Passive ideation, risk factors present, or historical attempts. Requires safety planning and increased monitoring

Safety Planning

The Stanley-Brown Safety Planning Intervention is the evidence-based standard:

1. Warning signs that a crisis may be developing
2. Internal coping strategies the client can use independently
3. Social contacts who can provide distraction
4. Family members or friends who can help during a crisis
5. Professional and crisis resources to contact
6. Steps to make the environment safer (means restriction)

Documentation Requirements

Risk assessment documentation should include:

• The method and tools used for assessment
• Specific findings (ideation, intent, plan, means access)
• Risk and protective factors identified
• Your clinical judgement of risk level
• Actions taken (safety plan created, referrals made, consultation obtained)
• Follow-up plan

Document risk assessments in your progress notes and update the treatment plan as indicated. When risk is identified, your documentation of the duty to warn assessment and decision-making process is critical.