432 Suicide and Life-Threatening Behavior 44 (4) August 2014

© 2013 The American Association of Suicidology

DOI: 10.1111/sltb.12067

Suicide Risk Assessment and Risk Formulation

Part II: Suicide Risk Formulation and the
Determination of Levels of Risk
ALAN L. BERMAN, PHD, AND MORTON M. SILVERMAN, MD

The suicide risk formulation (SRF) is dependent on the data gathered in

the suicide risk assessment. The SRF assigns a level of suicide risk that is intended
to inform decisions about triage, treatment, management, and preventive inter-
ventions. However, there is little published about how to stratify and formulate
suicide risk, what are the criteria for assigning levels of risk, and how triage and
treatment decisions are correlated with levels of risk. The salient clinical issues
that define an SRF are reviewed and modeling is suggested for an SRF that might
guide clinical researchers toward the refinement of an SRF process.

The relationship between a suicide risk
assessment (SRA) and a suicide risk formu-
lation (SRF) is analogous to the relationship
between a list of ingredients and a recipe.
A recipe informs the cook of what ingredients
get mixed with what other ingredients and
in what order, at what temperature the mix-
ture gets cooked, and for how long. Unto
itself, the list of ingredients fails to inform
the individual of how the ingredients in the
dish are to be combined and to comprise
the desired final dish. Similarly, the factors
of risk that constitute an SRA (i.e., the pres-
ence vs. absence of predisposing, precipitat-
ing, and acute risk and protective factors)
represent the essential ingredients to inform
an SRF. An SRF must involve some under-
standing of how risk factors interact, exac-
erbate, and otherwise fuel heightened or
lowered risk of suicide, no less how they
ALAN L. BERMAN, American Association of
Suicidology, Washington, DC, USA, and MORTON
M. SILVERMAN, Department of Psychiatry, The
University of Colorado Denver School of Medi-
cine, Aurora, CO, USA.
Address correspondence to Alan L. Ber-
man, American Association of Suicidology, 5221
Wisconsin Avenue, N.W., Washington, DC
20015; E-mail: berman@suicidology.org
inform a clinical judgment about the level
of risk.
Surprisingly, there is little in the clin-
ical literature that trains to the development
of clinical judgment either via a model for
an SRF or an extended guideline for estab-
lishing levels of risk. Furthermore, the liter-
ature lacks studies on the reliability and
validity of clinical judgment as it relates to
SRF. What Motto (1989) noted remains
true almost a quarter century later:
to date we have no established and
generally accepted procedure to guide us
in [the assessment of suicide risk]. Innu-
merable decisions regarding risk are
made and implemented every day—the
job gets done—but how it gets done is
determined primarily by the skills and
philosophy of the individual clinician. (p.
245)
The detection of suicide risk, the
determination of the level of risk, and the
consequent triage and treatment decisions
that are dependent on that determination
are, perhaps, the most significant judgments
a clinician must make. The failure to rea-
sonably accomplish these tasks has the
BERMAN AND SILVERMAN
potential for significant negative outcomes
for both the patient (a possibly preventable
death by suicide) and the clinician (a pre-
ventable loss of a patient). It is time for the
field of suicidology to move beyond the
intuition and philosophy of the clinician
(which can be idiosyncratic and/or unreli-
able), and to develop and train to models
for formulating a patient’s risk of suicide,
using standardized criteria and definitions.
Here, we offer a review of the salient
clinical issues that define an SRF, provide a
historical perspective on how clinicians have
been trained to make an SRF, and suggest
modeling for an SRF that might guide clini-
cal researchers toward refinement and valida-
tion as a trainable guide to clinical judgment.
A BRIEF HISTORICAL
PERSPECTIVE
It is instructive to view the question
of how—and if—SRF has been taught over
the years. This can indirectly be carried out
through the lens of major and significant
psychiatric textbooks and other writings
from the last century.
Two volumes written in the 1940s
(American Psychiatric Association, 1944;
Zilboorg & Henry, 1941) outlined the his-
tory of psychiatry and medical psychology
to the dates of publication, with scant ref-
erence to even the word suicide, no less
mention of how SRFs may have been con-
ducted or taught. Similarly, the American
Psychiatric Association’s One Hundred Years
of American Psychiatry (1944) makes no
mention of suicide risk, an SRA, or an
SRF. A third history of psychiatry volume
(Alexander & Selesnick, 1966) strikingly
does not even reference the word suicide in
its index!
Writing in Arieti’s classic American
Handbook of Psychiatry (1959), Levine and
Lederer argued that “direct and helpful
information” (p. 1926) such as the recogni-
tion and evaluation of suicide risks should
be given by teachers of psychiatry to stu-
dents in medical training. Yet the only
433
direct instruction offered in this two-vol-
ume tome was that given by Stevenson and
Steppe, who recommended, “to begin with
the thought content of the depressive mood
and work gradually upward to possible sui-
cidal thoughts” (p. 228).
Shneidman, writing in Freedman,
Kaplan, and Sadock’s The Modern Synopsis of
Comprehensive Textbook of Psychiatry/II
(1975; pp. 870–874), offered “prodromal
clues to suicide” and a discussion of the
concepts of perturbation, inimicality (hostil-
ity), and lethality, but no direction as to
how judgments of level of risk were to be
made.
Mackinnon and Michels, in The Psy-
chiatric Interview in Clinical Practice (1971,
pp. 204–209), wrote of the need for active
inquiry and discussion of suicide in the psy-
chiatric interview, noting the latter “[was]
crucial in gauging the severity and danger
of the patient’s depression” (emphasis added).
Their discussion on evaluating suicide risk
(pp. 414–415) only in this context of
depression, however, offers nothing to
guide clinical judgment.
Early suicidology researchers attemp-
ted to build instruments for evaluating “sui-
cide potential.” In the 1960s, clinicians at
the Los Angeles Suicide Prevention Center
(Farberow, Heilig, & Litman, 1968) began
constructing a “suicide potential scale” to
evaluate a patient or caller who identified
him- or herself as suicidal. Ten categories
of observations, including more than 60
individual weighted items, constituted a
summated score and relatively differentiated
risk ratings ranging from low to high. High
risk was conceptualized as “a prediction of
suicide probability” of 10,000 per 100,000.
Contemporaneously, Tuckman and Young-
man (1968) developed a scale for differenti-
ating high versus low suicide risk among
those who had made an attempt (defining
high risk operationally as death from suicide
within 1 year of the attempt). Using a data
set of more than 1,000 nonstandardized
police death investigations, these research-
ers ultimately presented 14 risk factors
associated with high risk. Neither of these
434
early efforts was ever replicated, nor vali-
dated.
Cohen, Motto, and Seiden (1966) clas-
sified suicide attempts of 193 inpatients into
one of four grades of seriousness and fol-
lowed these patients over a 5- to 8-year per-
iod to identify those who were at high risk;
that is, made a subsequent attempt or died
by suicide. Ultimately, they derived a 15-
item Suicide Risk Assessment Scale (SRAS)
with weighted scores totaling over 800 and a
“table of risk” ranging from “very low” to
“very high” (defined as a score > 555, having
an approximated suicide rate of over 10%
over the next 2 years). The SRAS was
intended to supplement, not substitute for,
clinical judgment and “when the Scale is not
consistent with clinical judgment, clinical
judgment [was to] be given precedence”
(Motto, Heilbrun, & Juster, 1985).
Perhaps the most significant contribu-
tion to developing an SRF was offered by
Beck, Resnik, and Lettieri (1974) at the
National Institutes of Mental Health
(NIMH) in the early 1970s. These research-
ers developed sophisticated models for for-
mulating risk among four demographic
groups defined by age and gender (old–
young, male–female), and, similar to earlier
scales, ratings of risk with scaled scores above
7 indicating high risk or the likelihood of
being dead by suicide within 2 years. That
none of these or other attempts to predict
suicide via research-based scales has survived
to offer a standard for clinicians was presaged
by Diggory (in Beck et al., 1974):
The intuitive, common sense combina-
tion of plausible suicide predictors into
scales for evaluating risk without system-
atic, empirical testing or verification has
been tried. … But, I believe that at pres-
ent hardly anyone seriously believes that
such a procedure is likely to fill the need
for better prediction. (p. 62)
Given the low base rate of suicide, it
has been intuitively understood by suicidol-
ogists that predictive scales, no less any
attempting actuarially to derive levels of
SUICIDE RISK ASSESSMENT AND RISK FORMULATION
risk of death by suicide, would produce far
more false positives than could be clinically
tolerated. To illustrate this, were we to
have a scale that was 95% accurate at pre-
dicting imminent risk (defined as death by
suicide within the next 48 hours) and were
we to apply this scale to 100,000 individu-
als, the scale would correctly find almost all
those who, indeed, would die by suicide,
but would simultaneously and falsely iden-
tify almost 5,000 individuals as imminently
at risk!
The need remains for clinical models
to inform clinical judgments about levels of
risk. Moreover, questions are raised as to
whether clinical judgments of risk are to be
based reasonably on science, or intuition, or
both, and whether good clinical judgment
regarding a patient’s relative level of suicide
risk can be trained.
WHAT IS MEANT BY “LEVELS OF
RISK”?
Traditionally, clinical professionals
evaluate a patient’s risk of suicide on a
quasi-Likert scale ranging from no risk to
low risk to moderate risk to high risk, and
whether high risk might be imminent risk.
However, standardized, operational defini-
tions of these levels of risk are difficult to
find. As noted by Simon (2011), models and
strategies for making judgments of levels of
risk have been proposed, but there is no
research that has specifically examined the
relative validity of any of these schemas, no
less the process and outcome of clinical
decision making that is intended to result
from an assignment of a level of risk. What
is generally understood by the clinician is
merely that these levels of risk exist on an
ordinal scale; that higher versus lower levels
of judged risk carry more significant
demands for aggressive treatment planning,
triage, and intervention; and that a determi-
nation of “imminent risk” is a statutory
requirement criterion for civil commitment
and potentially a clinician’s duty to warn
(Tarasoff v. Regents of the University of
BERMAN AND SILVERMAN 435

California, 17 Cal. 3d 425,551 P.2d334, sory time frame on an unpredictable act” (p.
131 Cal. Rptr. 14). 296).
The National Suicide Prevention
Imminent Risk Lifeline gives guidance to its affiliated crisis
call centers via its imminent risk policy
In the United States, statutes for which appears to align the crisis worker’s
assisted treatment (involuntary hospitaliza- judgment not with intuition, but with gut
tion) vary considerably (Berman, 2011a), feelings and anxiety. A caller is determined
but, typically, employ language to guide the to be at imminent risk of suicide if the cen-
clinician as follows: ter staff responding to the call believe,
based on information gathered during the
1. Real and present threat of substan-
exchange from the person at risk or some-
tial harm to self or others
one calling on his or her behalf, that there
2. Likely to injure if not thwarted
is a close temporal connection between the
3. Unable to care for self
person’s current risk status and actions that
4. … in the reasonable future
could lead to his or her suicide. The risk
must be present in the sense that it creates
As the reader may note, these statu-
an obligation and immediate pressure on
tory provisions offer language that leaves
center staff to take urgent actions to reduce
the determination of imminent risk entirely
the caller’s risk; that is, “if no actions were
up to the clinician’s best judgment applied
taken, the center staff believes that the
to a subjectively determined timeline (i.e.,
caller would be likely to seriously harm or
some undefined number of hours into the
kill him/her self” (www.suicidepreventionli-
future, e.g., 24, 48, or 72 hours).1 Hence,
feline.org/crisiscenters/bestpractices).
imminent risk determinations are clinical
In making a judgment of imminent
and temporally related predictions of behav-
risk, the clinician is asked to reasonably
ior in the near future (with no agreed-upon
anticipate the possibility of a patient’s poten-
operational definition of what is meant by
tially lethal suicidal behavior in the very near
the “near future”).
future; hence, to act to protect the patient.
No less, the demand to make such a
Therefore, this judgment is central to deter-
near-term prediction of a patient’s behavior
mining liability (whether a breach in the
asks clinicians to do considerably better than
standard of care occurred) in the assessment
meteorologists making near-term predictions
and treatment for a patient now dead by sui-
of precipitation. In spite of significantly bet-
cide. In the legal context, this judgment is
ter and more scientific instrumentation (e.g.,
one of “foreseeability.” Again, if the court
Doppler Radar) and computer models for
holds clinicians accountable for formulating
these predictions, meteorologists have been
a patient’s imminent risk of suicide, should
shown to be wrong more often than right in
we not try to base this judgment on some-
their predictions for the next 48 hours (www.
thing more than intuition?
freakonomics.com/2008/04/21/how-valid-are-
tv-weather-forecasts/). Simon (2006) was cor-
Just How Reliable Are Clinicians’
rect when he wrote that this near-term
Judgments of Levels of Risk?
prediction of imminent risk “imposes an illu-
Cahill and Rakow (2012) investigated
1
An oft-quoted reference (Hirschfeld & differences in clinical judgment using 35
Russell, 1997) defines imminent risk as a suicide hypothetical case examples provided to seven
attempt occurring within 48 hours of the time practitioners by regressing 10 case variables
that the patient is seen, short-term risk as an
attempt occurring within days or weeks, and onto their judgments, and found that all but
long-term risk as an attempt occurring within two potential risk factors were related to risk
weeks to years. and priority judgments. Further, they
436
observed that “low risk” might be particu-
larly subject to variability in its interpreta-
tion. Even the term risk could be ambiguous,
they noted, “reflecting the probability of
occurrence for some” and “the severity of
occurrence to others.” Perhaps, then, it
should not surprise us that Appleby and col-
leagues (Appleby et al., 2012; Appleby,
Shaw, & Amos, 1999) reported that, at last
contact, the therapist assessed no suicide risk
in 30% and low risk in 54% of patients who
then died by suicide.
Clinicians tend to believe that clinical
judgment improves with increased educa-
tion, training, or experience. However, clin-
ical experience and “expertise” add little to
the accuracy of clinical judgment (Hilton,
Harris, & Rice, 2006). As one illustration of
this, Berman (2011a) presented two case
vignettes (of persons who died by suicide)
to clinical suicidologist experts (blinded to
case outcome) and reported that only
between 30% and 40% rated these patients
at imminent risk. If critical clinical thinking
is influenced by knowledge and experience
(Bittner & Tobin, 1998), we have yet to
validate it. Indeed, a meta-analysis of 75
clinical judgment studies involving more
than 4,600 clinicians concluded that educa-
tion and clinical experience have a very
small effect (only 13%) on the accuracy of
clinical judgments (Spengler et al., 2009).
MODELS FOR FORMULATING
SUICIDE RISK
As regression models and other statis-
tically based methods of combining, scaling,
or otherwise actuarially integrating suicide
risk factors into some sort of formula for
judging level of risk have been shown to have
poor specificity (Schiepek et al., 2011), an
alternative approach to this standard of care
clinical responsibility needs to be found.
An SRF involves integrating informa-
tion derived from an SRA through an inferen-
tial cognitive process. The information
gathered through an SRA is potentially com-
plex and often ambiguous, in part because at-
SUICIDE RISK ASSESSMENT AND RISK FORMULATION
risk patients are inherently complex and their
communications are often indirect or pur-
posely unclear. Yet, this is the input that a cli-
nician must use to derive a judgment that
defines a level of risk. Motto (1992) wrote, “If
we cannot predict suicide, what can we do? …
We can … predict the risk of suicide rather
than the suicide itself. … There is no avoiding
subjectivity … what I have referred to … as
an intuitive judgment.” In the same volume,
Maltsberger (1992) wrote, “Because no one
knows how to integrate [a large mass of data]
… precisely and with empirical certainty, the
clinician is forced to rely on clinical experi-
ence and inductive reasoning” (p. 38).
Shea (1999, 2012) argued that the
clinical formulation of risk is based on a
cognitive understanding of data gathered
about risk, ideation, and protective factors
and an intuitive process that takes into
account such factors as the clinician’s famil-
iarity with the patient and the patient’s
character structure. Although he offers case
examples of his judgment based on these
databases, he provides no further direction.
Fawcett et al. (1990) provided ground-
breaking research by prospectively studying
954 mood disordered patients and, based on
those who died by suicide over the next 2 to
10 years, differentiated acute (from weeks up
to 1 year) versus long-term risk factors.
Simon (1992) incorporated these short-term
(although now not limited to their empirical
context within mood disordered patients)
and long-term variables, rating each on a
scale from low to high, or as a nonfactor, and
judged overall as a clinical mosaic, which he
later termed a “systematic suicide risk assess-
ment” (Simon, 2012). However, neither
approach clearly outlines how to formulate
levels of risk, especially when an individual
has risk factors which are not all “short
term,” “acute,” or “long term.”
Nevertheless, Maltsberger (1986,
1992) suggested roughly grouping personal
factors (p), exterior factors (e), and mental
state factors (ms) and then proposed that
risk (R) will be a rough function of the sum
of these: R = f(p + e + ms)/f(c), with
c = character = disposition to react
BERMAN AND SILVERMAN
adaptively versus maladaptively to emo-
tional injury.
Based on Joiner’s (2005) interper-
sonal-psychological theory of suicide and
research (Van Orden, Witte, Gordon,
Bender, & Joiner, 2008), a more recent
model adopted by the National Suicide Pre-
vention Lifeline asserts that desire, intent,
and acquired capability, in a context of low
buffers or connectedness, are associated with
imminent risk. While the individual compo-
nents of these factors have support for their
association with greater lifetime risk of sui-
cide, no test of the asserted combination of
desire, intent, and capability and imminent
or even near-term risk has yet been made.
Moreover, some of the observations that
define these components are problematic.
For example, capability is defined by any of
four observed behaviors: an attempt in pro-
gress, planning, preparation, and expressed
intent to die. As noted in our companion
article on SRA (Silverman & Berman, 2013),
that a great many persons who die by sui-
cide do not display any of these behaviors
dooms this model to failure in determining
a great number of “imminent suicides.”
That said, research attempting to validate
this model is warranted and desired.
About 4% of patients hospitalized for
a medically serious suicide attempt can be
expected to die by suicide within 18 months
after hospital discharge (Beautrais, 2004),
and more than 1% of psychiatric patients
die by suicide within a year of discharge
(Ho, 2003). A recent systematic meta-analy-
sis of controlled studies (Large, Sharma,
Cannon, Ryan, & Nielssen, 2011) investi-
gated risk factors for suicide within 1 year
after discharge from a psychiatric hospital.
Factors weakly associated with postdis-
charge suicide were reports of suicidal ideas
(OR = 2.47) and a diagnosis of major
depression (OR = 1.91). Patients deemed to
be high risk were more likely to die by sui-
cide than other discharged patients, but the
strength of this association was not much
greater than the association with some of
the individual risk factors. These authors
concluded that no one factor, or combina-
437
tion of factors, was strongly associated with
suicide in the year after discharge and, fur-
ther, that risk categorization is of no value
in efforts to decrease the numbers of
patients who will die by suicide after hospi-
tal discharge. Our interpretation of this
meta-analysis is that the low-risk patients
may have been misdiagnosed or poorly
assessed, in part because once they denied
SI they were deemed to be free of suicide
risk and ready for discharge (see Silverman
& Berman, 2013).
A PROPOSED MODEL BASED ON
EVIDENCE-BASED ACUTE RISK
FACTORS
The American Association of Suicidol-
ogy’s Recognizing and Responding to
Suicide Risk (RRSR) clinical training pro-
gram’s model for conducting an SRF asserts
that the presence of chronic risk factors
establishes the patient’s lifetime vulnerability
to be suicidal across his or her lifetime, while
the presence of one or more warning signs
(acute risk factors—see Rudd et al., 2006), in
that context of lifetime vulnerability, estab-
lishes a basis for the foreseeability of near-
term risk (see www.suicidology.org). We
offer this model for an SRF as it builds on
Litman’s (1990) conceptualization of a “sui-
cide zone,” in which he proposed that vul-
nerable individuals move in and out of
periods of heightened risk when a lot of
things (symptomatic, environmental, etc.)
occur at once. The model further assumes
that the greater the number of warning signs,
the greater the risk of death by suicide,
although no actuarial statement is made
about cutoff scores (e.g., number of acute
risk factors needed to define imminent risk).
That this may yet be possible, however, is
evidenced by Berman (2011b), who reviewed
55 psychologically autopsied suicides of
Americans who died on railroad rights-of-
way and found five or more of the 10 warn-
ing signs captured in the acronym IS PATH
WARM (www.suicidology.org) in the major-
ity of cases (55%), and three or more of the
438 SUICIDE RISK ASSESSMENT AND RISK FORMULATION

Threat of loss of position or identity

warning signs in 84% of cases. The RRSR
approach asserts that protective factors do

Contributory risk factors

not buffer when acute risk is present. In our
legal work, we have encountered too many
cases of individuals who had died by suicide
who were married with children, were reli-

Firearm accessibility
gious leaders (see case illustration), were in

Financial strain
treatment with a mental health professional,
or had future plans, to assert that protective

Religiosity
factors actually do protect when factors of

Buffers
acute risk are present in an already vulnera-
ble individual.

Case Illustration

Increased alcohol use

Increased withdrawal

protective influence of his religious attachment, puts Father Bill at

Acute risk factors
Father Bill, a 45-year-old Catholic

Multiple acute risk factors in a context of elevated lifetime risk, in

high suicide risk of the near-term (at the least until the audit is
spite of no stated suicide ideation and the once but now fragile
priest, enters treatment because he has been

Feeling trapped
Hopelessness
feeling mildly depressed and anxious. At his
initial session, he describes an increasing
Insomnia
Anxiety
level of panic in anticipation of an upcom-

Rage
ing audit of his parish finances, because he
had improperly advanced to himself, then

accomplished and his fears are not realized)

repaid most, but not all, of his salary to
help support his younger sister who has
Family history of depression and suicide

severe medical problems. Further, he

describes feeling rage at the Church’s lack
Diabetes, cardiovascular problems

of response to this sister’s claims that she

Chronic risk factors

had been sexually abused by her parish

History depressive episodes

priest years earlier. Father Bill believes the

audit was ordered as retaliation against him
for his support of his sister’s claim. Father
Middle-aged male

Bill appears fatigued and jittery, and com-

plains of symptoms of insomnia, problems
concentrating, hopelessness, and a fear that
Smoker

he would not be able to cope with an

impending demotion. As a result, he has
withdrawn from friends and supporters. He
denies thinking about suicide, but admits to
a family history of depression (his mother)
SRF case formulation: Father Bill

and suicide (a maternal uncle). He has a

chronic history of diabetes and has had car-
diovascular problems that have necessitated
Level of risk formulation

two surgical interventions in the past dec-

ade. Subsequent to these, his primary care
physician put him on antidepressants for
brief depressive episodes. In spite of this
history, he continues a 30-year cigarette
habit. He drinks occasionally but has
recently increased both the frequency and
amount of his drinking. He owns a firearm.
BERMAN AND SILVERMAN
As a related example of this model,
not all overweight, smoking, drinking, dia-
betic older men are going to have a myo-
cardial infarction (low-to-moderate risk
level), but those men with these risk factors
who also complain of shortness of breath
and chest pain (warning signs) are at high
risk of a myocardial infarction—although
not all men presenting with the warning
signs of shortness of breath and chest pain
are currently experiencing a myocardial
infarction or are destined to develop one.
Unfortunately, we yet lack research
into very near-term risk factors for suicide.
Warning signs (Rudd et al., 2006) were
identified by their association with suicide
over the subsequent 12 months, not the
next 30 or 7 days or, for that matter,
48 hours. There is a pressing need for this
research to be conducted. In fact, the
Research Task Force of the National Action
Alliance for Suicide Prevention has priori-
tized the assessment of who is at risk of sui-
cide in the near future as one of its 12
aspirational goals (http://actionalliance
forsuicideprevention.org/task-force/research-
prioritization).
The outcome of an SRF is a disposi-
tion. In an emergency department, for
example, there are at least five dispositional
outcomes from an SRF: release without fol-
low-up or recommendation for further
treatment, release with recommendation for
follow-up outpatient care, release with crisis
management and safety planning interven-
tions, release with ongoing interventions
(psychotherapy and/or medications), or hos-
pitalization (for safety and further assess-
ment). In this case, the patient, more than
likely, is at the emergency department
because of suicidal behavior or suicide idea-
tion; hence, triage decisions would have to
include an assessment of the patient’s sup-
port system, evidence of controls over SI
and/or subsequent attempt, ability to coop-
erate, and degree of resolution of life crises
that prompted the admission, in addition to
an assessment of current acute risk factors.
Similarly, these variables might be consid-
ered in an outpatient setting to help guide
439
dispositional decision making about the
need for hospitalization.
In this spirit, the SAFE-T pocket
card was developed by Screening for
Mental Health and the Suicide Prevention
Resource Center. In giving guidance on both
the assessment and formulation of risk,
it links a judgment of risk level with recom-
mended disposition. The downside is that it
maintains a focus on current SI or suicidal
behavior as a separate and integral category
of observation in informing that judgment
of level of risk (www.sprc.org/library/
safe_t_pcktcrd_
edc.pdf).
A NOTE ON CLINICAL
JUDGMENT AND ITS
TRAINABILITY
Clinical errors are both universal and
inevitable; however, clinical judgments, par-
ticularly those made under the stress of
seeking to be lifesaving, may be especially
prone to error. In one study, for example,
researchers were unable to predict nearly
two-thirds of the violent crime that ulti-
mately occurred and nearly two-thirds of
the persons whom they predicted would be
violent were not (Monahan, 1984). As noted
by Karthikeyan and Pais (2010), “clinical
judgment conjures up visions of the arche-
typal clinician endowed with infinite wis-
dom and breathtaking clairvoyance”
(p. 623). We recognize that creating clini-
cians in this mold is an unattainable goal.
As for whether education and/or
training can improve the accuracy of clinical
judgments, the jury is still out (Spengler
et al., 2009). Of course, in the arena of risk
formulation, the criterion variable against
which judgments of risk would be measured
is that of a suicidal behavior; that is, a
patient judged to be at a higher level of risk
of a suicidal outcome would, indeed, engage
suicidal behavior more frequently than a
patient at a lower level of risk. Given the
low base rate of suicidal behaviors among
patients, addressing this question would
440
require a very large number of patients to
be followed over a very long period of time.
For example, in Schulberg et al.’s (2005)
study of 761 primary care patients with
uncomplicated depression and suicide idea-
tion who were followed up over 6 months,
there were no deaths by suicide and only
one patient made a suicide attempt of
unknown level of potential lethality; that
patient had been judged to be of intermedi-
ate (moderate) risk at baseline.
Nevertheless, the American Associa-
tion of Suicidology’s Task Force on Train-
ing (Schmitz et al., 2012) has made
multiple recommendations for preventing
suicide through improved training (in this
case, to make a level of risk judgment)
focused on building essential skills. The
question remains as to whether training can
improve these skills and, if so, through what
methods of training.
While it is tempting to seek actuar-
ial models for predicting a patient’s risk
of violence (in contrast to relying on
purely clinical judgment), there is evidence
to suggest that these models may not be
superior (Litwak, 2001). Further, the ques-
tion remains as to whether suicidology
will ever be able to model statistically
those decision rules that would better
inform the accuracy of clinical judgments
(Dawes, Faust, & Meehl, 1989; Levine &
Levine, 2007; Swets, Dawes, & Monahan,
2000). As Nakash and Alegria (2013) have
suggested, the cognitive processes involved
in clinical judgment include an apprecia-
tion of nonverbal cues and affective com-
munications from patients (and hence have
termed these processes “implicit clinical
judgment”); the potential to create a via-
ble actuarial model that fails to capture
these inputs is questionable.
THE NEED FOR EMPIRICAL
RESEARCH
As noted, there is a need for a great
deal of research to inform an SRF—includ-
ing research on risk factors associated with
SUICIDE RISK ASSESSMENT AND RISK FORMULATION
very near-term risk; research validating
models for an SRF that tests which of the
many components of the SRA and to what
degree does the frequency, duration, inten-
sity, timing, and so forth of each of these
components determine the appropriate level
of risk in an SRF; and research on how
clinicians should best weight clinical infor-
mation and observations to determine level
of risk judgments.
Clinicians deserve a better roadmap
or clinical tool to assist in assigning an indi-
vidual to a level of low risk, medium risk,
high risk, acute risk, or imminent risk of
suicide. Without such an understanding of
relative contributions or weights to calibrate
an individual’s level of suicide risk, the cli-
nician is left to his or her education, train-
ing, intuition, judgment, and prior
experience to determine how best to inter-
vene and manage the patient. We believe it
is necessary to bring as much science into
this process as is possible. Despite the obvi-
ous appeal, it remains dangerous and unpre-
dictable to rely on clinical intuition or
experience in arriving at a judged risk level
for an individual, especially when their life
or death hangs in the balance.
As noted by Berman (2012), “Perhaps
there is no equally compelling patient and
patient problem in the mental health arena
as that of the suicidal patient where our
gaps in understanding are so great and our
opportunities for making a difference are so
profound” (p. 631).
CONCLUSIONS
Stratifying a patient’s level of risk of
suicide through an SRF has significant
implications for clinical outcomes and
hence for the patient at risk. For example, a
patient judged to be at imminent risk may
be hospitalized, perhaps against his or her
will, consequently be enraged at the mental
health system, be turned off to further help-
seeking (upon discharge), and become yet
more suicidal as a consequence. Moreover,
as clinicians are potentially held accountable
BERMAN AND SILVERMAN
through tort actions when, and if, a patient
in treatment dies by suicide, improving the
clinical judgments involved in clinical deci-
sion making regarding the triage and treat-
ment for these patients has significant
implications for the clinician. Some (Ryan,
Nielssen, Paton, & Large, 2010) have gone
so far to argue that risk formulations should
not form the basis for clinical decision mak-
ing, preferring to focus attention simply on
the treatment needs of each patient, regard-
less of risk of adverse events. We agree that
a patient’s treatment needs should be fore-
most in the mindset of the clinician, but, in
litigious societies, this argument (against
conducting an SRF) has serious negative
consequences for the clinician.
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Manuscript Received: June 11, 2013
Revision Accepted: October 3, 2013