Evaluating suicide risk requires a standardized method to ensure individuals experiencing distress receive consistent and appropriate care. In clinical settings, the potential for self-harm is one of the most serious situations, demanding a swift and structured response. A formalized protocol helps mental health professionals systematically gather information, make informed decisions, and coordinate immediate interventions. This structured approach streamlines the process of identifying risk factors and translating that information into a clear plan of action, minimizing variability in assessment quality and ensuring patient safety.
Understanding the Purpose and Context of SAFE-T
The Suicide Assessment Five-Step Evaluation and Triage protocol (SAFE-T) is an evidence-based tool developed to guide clinicians through assessing suicide risk. Its goal is to provide a uniform framework for evaluating a patient’s risk level and determining the necessary level of care. SAFE-T was developed by Dr. Douglas Jacobs and is promoted by organizations like the Substance Abuse and Mental Health Services Administration (SAMHSA).
This protocol is utilized by a wide range of professionals, including psychiatrists, therapists, emergency room physicians, and crisis intervention specialists, across various settings. The structured nature ensures that the fundamental components of risk assessment are covered regardless of whether the assessment happens in an outpatient clinic or a busy hospital emergency department. The “Triage” part of the name emphasizes the immediate decision-making process that follows the assessment, determining the appropriate setting and intensity of intervention needed.
The SAFE-T protocol is built upon three core components: systematic assessment, risk stratification (triage), and thorough documentation. It should be used not only at a patient’s first contact but also with any subsequent change in their mental state or before a change in treatment, such as discharge from an inpatient facility. The standardized checklist and flow help clinicians meet the minimum standard of care for suicide risk assessment.
Step-by-Step Guide to the Five Assessment Stages
The SAFE-T protocol is structured around five distinct, sequential steps. The process begins with Step 1: Identify Risk Factors, which involves noting characteristics that statistically increase the likelihood of suicidal behavior. These factors include a history of prior suicide attempts, mental health conditions (like depression or substance use disorders), access to lethal means, social isolation, prolonged feelings of hopelessness, and major life changes or losses.
The next stage is Step 2: Identify Protective Factors, focusing on elements that buffer an individual against suicidal thoughts and actions. Clinicians look for factors that can be enhanced to reduce risk, such as strong family or social connectedness, effective behavioral health care, internal coping skills, and reasons for living (like children or pets).
The third step, Step 3: Conduct Suicide Inquiry, involves a detailed investigation into the patient’s current suicidal thoughts, plans, behaviors, and intent. This inquiry focuses on the frequency, intensity, and duration of ideation, examining its presence within the last 48 hours and past month. The clinician must explore the details of any plan, including timing, location, lethality, and availability of means, as well as any preparatory acts. A thorough inquiry also differentiates between past attempts and non-suicidal self-injurious actions, evaluating the patient’s actual intent.
Following the inquiry, the clinician moves to Step 4: Determine Risk Level, synthesizing all gathered information. This stage requires clinical judgment to categorize the patient’s overall risk based on the balance of identified risk and protective factors and the specifics of their current suicidality. This categorization dictates the urgency and nature of the subsequent intervention. The final stage is Step 5: Document, where the clinician records the comprehensive assessment, the rationale for the determined risk level, and the treatment plan for legal and continuity-of-care purposes.
Determining Risk Levels and Establishing Safety Plans
The synthesis of risk and protective factors leads to the assignment of a risk level: low, moderate, or high.
Low Risk
A low-risk designation applies to individuals who report only thoughts of death without a specific plan, intent, or behavior, and who possess modifiable risk factors and strong protective factors. Interventions often include outpatient referral, symptom reduction treatment, and providing emergency crisis numbers.
Moderate Risk
A moderate-risk assessment involves multiple risk factors and few protective factors, often accompanied by suicidal ideation with a plan but without strong intent or specific behavior. This level necessitates a crisis plan and closer monitoring, and admission may be considered depending on the overall clinical picture.
High Risk
A high-risk determination is assigned when severe symptoms are present, protective factors are non-existent, and there is a potentially lethal suicide attempt history or persistent, highly intentional ideation. Admission to a psychiatric facility is generally indicated for high-risk individuals, along with immediate suicide precautions.
Regardless of the risk level, the SAFE-T protocol emphasizes the development of a Safety Plan as a core intervention, particularly for those who are not admitted. This personalized, prioritized list of coping strategies and sources of support is a collaborative, written document. It includes identifying internal coping strategies (e.g., listening to music), listing distracting people and social settings, and providing contact information for professionals and support systems. A crucial element involves counseling on and restricting access to lethal means, with a clear follow-up plan established.