SAFE-T Tool for Suicide Risk Assessment

The SAFE-T tool is a five-step process for suicide risk assessment based on the Practice Guidelines for the
Assessment and Treatment of Patients With Suicidal Behaviors, it gives clinicians a series of steps to check for in performing suicide risk assessments to make sure that they are meeting the minimum standard of care.

The five elements (which are also available on a pocket card) are:

• Identify Risk Factors
• Identify Protective Factors
• Conduct Suicidal Inquiry
• Determine Risk Level/Intervention
• Document

Each of these elements is explored more fully below.

Identify Risk Factors

Risk factors include elements that increase risk on a demographic basis, rather than warning signs (which are imminent signs of someone planning suicide). They include:

• History of prior suicide attempts
• Mental health issues
• Depressive symptoms
• Family history of suicide attempts
• Current substance abuse
• Major life changes/loss
• Change in treatment (e.g. recently discharged)
• Access to lethal means

Some of these (for instance, current substance abuse and access to lethal means) can and should be mitigated in clients where this is possible. Other factors like a history of prior suicide attempts, and a family history of suicide attempts can’t be mitigated but you should stay aware.

Identify Protective Factors

Protective factors, being the opposite of risk factors are things that lower a person’s suicide risk. These may also be spoken of in terms of “hooks”, reasons that a person keeps holding on and does not attempt suicide. They include:

• Friends and family (positive social relationships)
• Connection to a religion that prohibits suicide
• Peripheral resources like physicians, counsellors, etc.
• Future hopes and dreams
• Internal coping skills
• Children
• Pets

Again, you can work to remind and improve clients of their connections to their pets, their children, and to peripheral resources like counsellors and doctors. An additional resource that may help you explore this is my article on Building Your Support Network.

Conduct Suicidal Inquiry

This element of the SAFE-T tool involves exploring the details of the client’s plan, intensity of suicidal thoughts and their intent.

Some questions suggested by the items in this part of the tool include:

• How long have you been feeling suicidal?
• Do you have a plan? (remember to explore if they have access to this plan)
• How intense are your suicidal feelings?
• Have you made any preparations to put your plan in motion?
• Do you expect the plan to kill you, or just injure you?
• Do you expect to be rescued?
• Have you ever rehearsed your plan?

This will help you explore the depth of the client’s suicidal thoughts and get a feel for how suicidal they are. Remember that suicidality can change minute to minute or hour to hour, but this will give you an idea where they are in the moment you’re talking to them.

The CPR Risk Assessment can also help you explore this particular part of the suicidal process for that person.

Determine Risk Level/Intervention

The next task is to determine the actual level of risk. Often tools conceptualize this as Low, Medium, or High Risk, though there are issues with this (someone who is low risk could still go on to attempt or die by suicide while plenty of people who are high risk do not.)

This involves an element of clinical judgement and weighing the risk and protective factors on your own. This is why untrained and low-trained individuals cannot perform suicide risk assessments without close supervision, and all others should still not without regular supervision.

Document the Assessment

Finally, documenting the risk assessment involves writing out the above information, your reasoning for coming to your decision and any recommendations about ways to limit suicide risk.

This is often overlooked by professionals in a hurry but should a client die by suicide, “If it isn’t written down, it didn’t happen.”