Crisis Response & Suicide Prevention in Residential Treatment

Components of a Comprehensive Suicide Risk Assessment 

Every patient admitted to residential settings is evaluated for their risk of suicide. The evaluation uses structured tools, and clinicians validate the results based on their judgment. 

The assessment checks for active suicidal ideation, intent, and plan via direct questions. The Columbia Suicide Severity Rating Scale (C-SSRS) is a validated tool used for this purpose.^[3] It asks for: 

• The frequency of suicidal thoughts.
• The intensity of those thoughts.
• Any suicidal behavior, including past attempts.
• Self-injurious behavior without suicidal intent. 
• Qualities, relationships, or beliefs that buffer against suicide risk. 

The suicide risk assessment looks for both risk factors and protective factors against suicide and weighs the two to determine the degree of clinical supervision needed for the patient. 

It also uses collateral information gathered from family members. This is because some people may minimize their suicidal ideation during a clinical interview, but involving a family member in the discussion can reveal a more significant risk.

Acute vs. Chronic Risk Factors 

Risk factors for suicide exist on a spectrum. 

A suicide prevention program distinguishes between acute factors that intensify risk in the immediate or near term and chronic factors that increase the risk of suicide at a baseline level. 

Acute risk factors include: 

• Recent suicide attempts.
• Discharge from psychiatric hospitalization.
• Recent loss or bereavement.
• Relationship issues.
• Financial crisis.
• Intoxication with alcohol or other substances.

Access to means of a suicide attempt, such as obtaining a firearm or stockpiling medications, is also considered an acute change in risk profile. 

Chronic risk factors are longer-standing factors that increase the chances that a person will think about suicide. They can be: 

• Major psychiatric diagnoses like major depression, bipolar disorder, schizophrenia, and borderline personality disorder. 
• Substance misuse or dependence.
• Chronic pain.
• Chronic medical conditions.
• Unstable housing and relationships.
• Social isolation.
• Hopelessness.

Occupational exposure, which includes access to means of suicide through military service, law enforcement, or medical professions, also increases the chronic risk of suicide.  

The presence of both acute and chronic risk simultaneously creates the highest level of danger. 

Documentation and Safety Planning After Assessment 

After an assessment is complete, the risk level of the patient is documented in their medical records so that every member of the treatment team knows about it. It also determines the degree of observation required for a patient while they are in residential treatment. 

Based on the documented risk assessment, a safety plan is created for every person. Also, the safety plan is a collaborative document developed together with the patient rather than something imposed upon them. 

The safety plan identifies personal warning signs that indicate a person’s risk of suicide has escalated. It lists their triggers and coping mechanisms that help them in distress. 

The safety plan also includes: 

• Internal resources: It mentions what to do when someone feels like they cannot safely manage their thoughts while they are in a residential facility, how to call nursing staff, and so on. 
• External resources: Some aftercare resources for when someone gets discharged from residential treatment centers are also included, such as the National Suicide Prevention Lifeline (988) and Crisis Text Line. 

24/7 Monitoring and Observation

Every patient in a residential treatment facility is under 24/7 monitoring. The levels of formal observation in psychiatric nursing include: 

• Routine monitoring.
• 15–30 minute monitors.
• Constant monitoring.
• One-to-one monitoring.

At the lowest level – general observation – staff know your location at all times, but they are not within direct sight.

For patients at high risk for suicide, constant one-to-one visual observation is implemented. A qualified staff member is assigned to observe only one patient at all times, so that they can immediately intervene should the patient attempt self-harm. This 1:1 observation is continuous and includes all hours of the day and night. 

Many suicides in residential settings occur during documented gaps in observation. These include bathroom and sleeping areas, and during periods of relatively unstructured time. Therefore, some facilities use bathroom monitoring procedures, conduct room searches when indicated by risk level, and limit access to certain areas during high-risk periods.