Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Suicide and self-harm risk formulation
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Imminent suicidal action or serious injury
An act in progress, recent potentially lethal self-harm, current intent with available means, inability to delay action, severe intoxication or loss of a safe environment requires immediate emergency intervention.
Action: Treat physical injury and poisoning using the relevant emergency pathway, remove access to immediate means where safe, arrange continuous proportionate observation and obtain urgent mental-health assessment. Involve emergency services when the setting cannot maintain safety, assess capacity for each decision and document the lawful basis of any restriction or non-consensual information sharing.
Purpose and principles
Assess suicidal thinking and self-harm through a compassionate psychosocial assessment, formulate person-specific scenarios and changing drivers, and translate evidence, strengths and uncertainty into immediate safety actions without relying on predictive scores.
Create privacy, explain confidentiality limits and ask about suicide in plain language. Begin with the person's account of what happened and what they hoped would change. Explore passive wishes not to wake, active suicidal thoughts, intent, method, timing, preparation, rehearsal, access, perceived lethality, steps taken to avoid discovery and likelihood of acting. Ask what interrupted action, what makes the next hours dangerous and what support is acceptable. Calm, empathic direct questions do not create suicidal ideas and can reduce ambiguity.
Self-harm is behaviour, not a diagnosis. Clarify the sequence before, during and after the act; expected outcome; planning; substance use; pain; dissociation; social context; medical consequences and response to survival. Do not infer low concern from superficial injury or high intent from tissue damage alone. Previous episodes inform patterns, but each presentation needs a fresh psychosocial assessment that includes mental state, physical health, medicines, substances, relationships, trauma, abuse, housing, finances, work, legal problems and dependants.
Indications, selection and cautions
Imminent pathway
Current intent, feasible method, available means, near-term timing and inability to use safety supports makes immediate intervention necessary.
Escalating dynamic state
Agitation, intoxication, sleep loss, humiliation, pain, psychosis or relationship rupture is worsening compared with the person's recent baseline.
Preparatory behaviour
Acquiring means, researching lethality, writing messages, arranging affairs or avoiding discovery can reveal intent not captured by a simple verbal denial.
Non-suicidal function
Self-injury may regulate emotion, interrupt dissociation or communicate distress, yet accidental death and later suicidal transition still require assessment.
Conditional protection
A person, value, routine or service can interrupt the specific risk sequence when it remains accessible and acceptable during crisis.
Red flags requiring action
A specific plan, rehearsal, final arrangements, concealed preparation, available lethal means or stated inability to remain safe markedly increases immediate concern even when the person appears calm.
Recent discharge, major loss, escalating pain, agitation, insomnia, intoxication, shame, command hallucinations or abrupt withdrawal from support can create rapid change in the risk pathway.
Method and interpretation
01Psychosocial assessmentFirst stepPreferred
Why
Understand the self-harm or suicidal crisis, needs, mental state, strengths, context and preferred help.
Interpretation and limitations
A needs-led assessment informs care and should not be replaced by a risk scale or checklist. Record the person's account and clinician formulation separately.
02Intent, plan and means enquiry
Why
Define current thoughts, preparation, capability, timeframe, access and barriers to action.
Interpretation and limitations
Specific feasible preparation increases immediacy, but denial does not overrule recent behaviour, collateral evidence or severe dynamic change.
03Longitudinal and collateral review
Why
Map previous acts, rescue, response, recovery, treatment and changes seen by trusted others.
Interpretation and limitations
Patterns can identify triggers and effective safeguards. Source, consent, discrepancies and possible coercion must remain explicit.
04Scenario-based risk formulation
Why
Connect foreseeable harm to triggers, symptoms, means, opportunity, warning signs and protective actions.
Interpretation and limitations
State what could happen and how interventions alter the pathway. Avoid converting uncertainty into a numerical probability or categorical label.
Clinical next steps
01Immediate responseTreat, contain and clarify dangerFirst stepSelf-harm has occurred or current suicidal action may be near.+
1Stabilise physical injury or poisoning, reduce immediate access to means and arrange observation matched to the actual environment and behaviour.
2Ask directly about intent, method, timing, preparation and ability to collaborate with safety while obtaining urgent collateral facts when needed.
3Arrange the least restrictive setting that can deliver necessary care, documenting capacity, legal basis, information sharing and the receiving clinician.
02Risk formulationDescribe scenarios, drivers and safeguardsEnough information exists to move beyond a factor list.+
1Define one or more plausible harmful outcomes, timeframes, triggers, available means and observable warning signs.
Risks, monitoring and follow-up
Reassess intent, capability, means and safety after sobriety, sleep, analgesia, treatment of psychosis or receipt of new collateral information.
Review access to medicines, firearms, ligatures, heights, transport and other scenario-specific means when circumstances or residence changes.
Track engagement, function, sleep, agitation, substance use and major stressors rather than relying on repeated risk scores.
Check whether the safety plan was usable during distress and revise contacts or steps that proved inaccessible, shaming or unsafe.
Increase review around discharge, rejection, bereavement, court events, medicine changes and service transitions identified in the formulation.
Special situations
Intent and injury diverge
Medical severity and desire to die are separate dimensions, so neither a superficial wound nor intensive-care admission answers the psychosocial question.
Denial is one datum
A stated absence of intent matters, yet preparation, intoxication, shame, recent acts and collateral information can support a different immediate formulation.
Prediction is not the task
Clinical work identifies needs, plausible scenarios and modifiable pathways rather than claiming certainty about a rare individual outcome.
Means are contextual
Ask about what is actually accessible in the person's home, work, vehicle and online purchasing environment, not a generic list alone.
Hope remains concrete
A small near-term commitment, safe place or reachable person can support survival without demanding that the person endorse broad optimism.
Common pitfalls
01
Using a screening score to predict suicide or decide discharge and treatment access.
02
Assuming superficial self-harm has little intent or severe injury always represents a wish to die.
03
Accepting a verbal denial without exploring preparation, access, recent change and collateral evidence.
04
Listing children, employment or faith as protection without testing how they function in crisis.
05
Obtaining a no-suicide promise instead of a practical collaborative safety plan.
06
Allowing physical treatment to prevent later psychosocial assessment, or vice versa.
07
Handover that communicates a risk label but omits scenarios, interventions and ownership.
Practice
Two practice questions
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Question 1 of 2
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PsychiatryOriginal SBA
Use of risk scales
A patient attends after self-poisoning. A numerical tool categorises future suicide risk as low, but the patient recently acquired more tablets and describes escalating hopelessness. What should guide care?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Formulation replaces false prediction with actionable explanation. Describe the feared outcomes, current drivers, historical vulnerabilities, means and opportunities, recent changes, warning signs and conditions that strengthen or weaken safety. A formulation might state that impulsive overdose becomes more plausible after alcohol use and conflict because medicines are stored at home, while early contact with a sibling and restricted tablet supply reduce opportunity. State uncertainty and alternative scenarios, including accidental death through escalating self-harm without stated suicidal intent.
Protective factors are conditional. Ask how a relationship, value, service, pet, child, belief or coping skill operates when the person is most distressed. Confirm availability, willingness and safety. A relative abroad or a crisis number the person cannot call does not protect the next night. Explore reasons for living without making the person defend their worth. Build the safety plan collaboratively and address means through safe storage, limited supply or removal with consent and household involvement where appropriate and lawful.
Disposition follows needs and immediate safety, not a score. Treat injury, intoxication, withdrawal, psychosis, mood disorder, pain and social crisis in parallel. Decide whether home, crisis care, general hospital or psychiatric admission can reliably deliver the necessary observation and intervention. If the person declines, assess decision-specific capacity and legal options; a capacitous refusal may still require proportionate information sharing to prevent serious harm. Provide rapid aftercare after self-harm, clear contacts and a named handover.
Key points
Ask directly about thoughts of death, self-harm, suicide, intent, method, timing, preparation, access to means, interruption and what has prevented action so far.
Establish the function and context of any self-harm, including relief, communication, punishment, dissociation, compulsion or suicidal intent, without assuming one purpose from the method.
Build a chronology of previous acts, lethality, intent, rescue, treatment and periods of recovery; recent change and trajectory often matter more than a static factor list.
Assess mood, psychosis, agitation, substance use, sleep, pain, physical illness, trauma, relationships, housing, finance, legal stress, access to care and safeguarding.
Formulate plausible scenarios: what harm may occur, under which triggers, with which means, in what timeframe, and which warning signs indicate escalation.
Identify protective factors and strengths, then test whether they are available and effective during the anticipated crisis rather than adding them as reassuring points.
Use collateral information and records with consent where possible; receive urgent safety information even when confidentiality prevents disclosing clinical details in return.
Agree a collaborative safety plan that includes warning signs, internal coping, safe people and places, professional contacts and practical restriction of lethal means.
A medically minor act may carry high suicidal intent, whereas severe injury may arise without intent to die; treatment need and psychosocial meaning must be assessed separately.
Children, dependants, work or religious belief are not automatic protection and may also contribute burden, guilt or entrapment.
Do not use a risk scale, global low-medium-high category or absence of a known risk factor to decide discharge, deny care or predict an individual suicide.
05
Physical and toxicological assessment
Why
Identify injury, poisoning, withdrawal, pregnancy, pain and medical factors that change urgency or treatment.
Interpretation and limitations
Follow substance-specific emergency pathways and do not delay treatment for a full psychiatric interview; repeat mental-state assessment after stabilisation.
2
Link historical vulnerabilities and current dynamic drivers to the sequence while testing the availability of each protective factor.
3State uncertainty and formulate interventions that interrupt specific points, including means restriction, treatment, social action and rapid contact.
03AftercareTransfer safety with ownershipThe immediate crisis is stabilised and the person is leaving the assessment setting.+
1Complete a collaborative safety plan in accessible language and confirm medicines, means, accommodation, dependants and supportive contacts.
2Provide a named follow-up route at the timing indicated by need, communicate the formulation and outstanding medical issues securely.
3Explain warning signs and emergency options, verify understanding and ensure missed contact triggers active review rather than automatic discharge.
Document the formulation, actions, capacity, information sharing, follow-up owner and uncertainty; reassess after sobriety, treatment, new information and transitions.