Suicide Safer Care Practices: The AIM Model

The AIM Model

The AIM model provides a helpful framework or roadmap for clinicians and clinical systems of care charged with reducing suicide risk. Developed by Dr. Barbara Stanley, Director of the Suicide Prevention, Training, Implementation and Evaluation program at Columbia University and the New York State Psychiatric Institute, the AIM model highlights three core domains of clinical practice essential to reducing suicide risk: 

  • Assess all individuals for suicide risk using evidence-based screening tools 
  • Intervene with at-risk individuals, using suicidespecific interventions 
  • Monitor at-risk individuals with increased follow-up contact and regular screening 

Assess

The Assess component of the AIM model synthesizes research on best practices for suicide risk detection. Drawing on findings that individuals who do not present with traditional symptoms of suicidality may nevertheless be at risk, the AIM model prescribes universal screening for all persons seen at behavioral or medical health facilities.1

Screening – To detect risk, the AIM model recommends the use of validated screening tools, such as the Screening Version of the Columbia Suicide Severity Rating Scale (C-SSRS).2  If an individual screens positive on a validated suicide risk screener, the AIM model encourages the use of a comprehensive suicide risk assessment. 

Comprehensive Suicide Risk Assessment – Used in conjunction with screening data, a comprehensive suicide risk assessment should provide a framework for documentation of a suicide risk formulation based on all risk and protective factors and access to lethal means, in order to help determine the level of care most appropriate for an at-risk individual.3  Ideally, information is collected from multiple sources, including treatment professionals and people well known to the patient with recent contact.

Foreseeable Changes (FCs) are events, which, if they occurred, could quickly and significantly increase suicide risk. Assessments of suicide risk capture a single moment in time, but things can change quickly; some individuals are ‘one major stressor away’ from being acutely suicidal. Identifying FC’s as part of the assessment explicitly acknowledges the fluid and unpredictable nature of suicide risk, and directly informs individualized contingency plans that can be developed in anticipation of changes that could increase risk. The Two Foreseeable Changes Intervention Guide explains how providers can help patients identify and plan for FCs. 

Suicide risk assessment should conclude with a prevention-oriented suicide risk formulation, which weighs risk factors and protective factors along with clinical judgement, to ascribe a level of risk for the specific individual presentation and treatment setting. 

The suicide risk formulation directly informs a suicide care management plan, which includes specific intervention strategies to mitigate risk. It is important to remember that even though a patient or client may be assigned a risk level (e.g. Moderate Risk), risk stratification should be used to drive prevention interventions, not prediction. Suicide risk assessment must  be on-going because suicide risk fluctuates over time 

A sample suicide risk assessment can be found here. 

Intervene

Integral to the AIM model is the principle that suicide risk should be targeted directly with suicide-specific interventions. The Intervene component offers evidence-based guidelines and tools for suicide prevention; treatment goals and objectives should focus on reducing modifiable risk factors and increasing protective factorsEffective interventions enable at-risk individuals to call on a range of strategies to delay acting on suicidal urges.  

Universal Precautions for Suicide Prevention 

It is well established that individuals with mental illness and/or substance use disorders are at increased risk of suicide. Unfortunately, an estimated 50% of suicide deaths occur among individuals making their first attempt i.e. their first attempt is a lethal attempt.4 Studies suggest that for many the time between first wanting to die and acting on that thought or impulse can be very short—minutes or hours, not days.5 Despite our knowledge of risk factors, we simply are not good at predicting which individuals will die by suicide. 

For all these reasons, we recommend ensuring that all patients receive basic psychoeducation on suicide risk and how they (and their friends and family members) can get immediate crisis support. This can be tailored to reflect each individual’s unique circumstances and risk and protective factors, but at a minimum should include: 

  • The fluid nature of risk of suicide – how things can change quickly 
  • The immediate period post-discharge from CPEP or Inpatient is a particularly high-risk time 

Please see the Universal Precautions Guide for Clinicians for more information. 

Safety Planning Intervention 

The Safety Planning Intervention for suicide prevention, developed by Drs. Barbara Stanley and Gregory Brown, is a prioritized list of six strategies for coping with suicidal urges typically developed collaboratively by an at-risk individual and their provider.6  As illustrated in this sample template, these steps include internal coping skills or distractions, social distractions, and the engagement of mental health professionals.  Drs. Stanley and Brown also developed the Safety Plan Intervention Brief Checklist [link to document] to assist clinical providers in completing the intervention. 

Lethal Means Safety and Counseling 

A critical part of the Safety Planning Intervention is reducing access to lethal means as well as clinician competency with counseling people at risk of suicide regarding their immediate safety. Because many suicide attempts occur with little planning during a short-term crisis, if the means to make the attempt have been temporarily removed/ secured or are made more difficult to access, it is likely that the suicidal urge will dissipate before any attempt is made. Therefore, putting time and distance between those at risk and access to any lethal means is critical to preventing suicide among those at-risk. This includes safe storage of firearms, prescription medication, and other high-risk items. Including family, friends and other supports, if appropriate, can be helpful in developing a plan to create safer environments around those who are at-risk for suicide. For more information, please see A Guide for Clinicians: Means Reduction Counseling.” 

ASSIP 

ASSIP (Attempted Suicide Short Intervention Program) is a promising, short-term intervention that has demonstrated a significant reduction in subsequent suicide attempts. Requiring only 3-4 sessions, the goals are for clinicians to listen to an individual’s story, help the person understand what led to their suicidal crisis, and find ways to establish effective coping strategies for the future. ASSIP is now available via Telehealth to individuals 18 years of age and above who are residents of New York State as part of ongoing research. It is designed to complement, not replace, other recommended treatment; the ASSIP team will coordinate with the client’s primary treatment team. For more information on ASSIP, please click here

Evidence-based Treatment Approaches 

There are several evidence-based treatment models that target suicidal behavior; most are designed for long-term, outpatient treatment, though some have been adapted for short-term settings, such as Inpatient: 

For more on evidence-based treatment, please click here. 

Monitor

The Monitor component of the AIM model provides guidance for enhanced monitoring for individuals at-risk of suicide. In Outpatient settings, a Suicide Safer-Care Management Plan would include an increase in clinical contact and screening for suicide risk in every clinical contact.  However, even with increased frequency of treatment sessions, a lot can change in between clinical contacts with a patient at elevated suicide risk.  It is important that patients who do not show up or cancel an appointment are followed up with on the same day, and that collateral contacts or mobile crisis services are considered if a provider cannot make direct contact. 

The well documented peak in suicide risk immediately following a psychiatric hospital discharge and low attendance rate of aftercare appointments are two reasons why monitoring after an Inpatient episode of care is so important.7  Structured follow-up phone calls provide crucial linkages and clinical support. Often, they include a brief assessment of suicide risk, review of a safety plan, and problem solving around overcoming barriers to connecting to outpatient care and/or community supports. Click here for a sample structured follow-up script.  

Non-demand caring contacts offer a less intensive form of engagement and monitoring than follow-up calls. They are typically brief communications with patients following an inpatient hospitalization or other care episode in the form of letters, e-mail messages, or text messages. Studies suggest caring contacts can be a cost-effective way to reduce suicide attempts, particularly for patients unlikely to engage in follow-up care.8 & 9 Finally, a host of phone or text-based crisis and support services are increasingly available as a source of support for those in distress. For a sample caring contact, please click here. 

It is also important that Inpatient and CPEP programs complete a “warm handoff” of records to the outpatient provider before the first appointment, which includes: 

  • Initial Suicide Risk Assessment 
  • Suicide Care Management Plan, which includes the Stanley Brown Safety Plan with lethal means reduction, and Two Foreseeable Changes 
  • Discharge Summary, including an updated suicide risk assessment, treatment recommendations for outpatient care including those specific to suicide risk, and barriers to both accessing care and reducing suicide risk 

Advances in Electronic Medical Records are making it easier to coordinate care through the sharing of AIM records.  

Putting the AIM Model into Practice

We suggest an approach where all patients that screen positive for suicide are placed on a Suicide Safer-Care Pathway with the level of care and type of interventions linked to suicide risk level.  At the very least (those at low-risk), patients will receive suicide prevention-based Universal Precautions and be periodically screened for suicide risk. 

Those at moderate and high-risk will receive interventions and monitoring tied to their elevated risk of suicide.  For example, in outpatient behavioral health settings, patients would be placed on a pathway called the HOPE Pathway.  Patients would be screened for suicide risk at every clinical contact; for example, providers can use the C-SSRS Since Last Visit screener. 

Engaging Family and Other Support People 

Family members and other social supports from within a suicidal individual’s natural environment can be engaged in the patient’s specialized treatment plan, now centered around suicide care, by enhancing patient safety and providing support to both the individual and treatment provider. For more on the benefits as well as challenges, please click here. 

Suicide Safer Care Practices by Setting

To learn more about adapting the AIM model to accommodate the unique challenges of different treatment settings, please visit our Suicide Safer Care Practices by Setting page.

References

 

  1. Brodsky B, Spruch-Feiner A, Stanley B. The Zero Suicide Model: Applying evidence-based suicide prevention practices to clinical care. Frontiers in Psychiatry. 2018;9:33.
  2. Chappell P, Feltner DE, Makumi C, Pharm D, Stewart M. Initial validity and reliability data on the Columbia-Suicide Severity Rating Scale. Am J Psychiatry, 2012;169:6 662–3.
  3. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry, 2003;160:11 Suppl 1–60.
  4. Bostwick JM, Pabbati C, Geske JR, & McKean AJ. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100.
  5. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19-24.
  6.  Stanley B, & Brown, GK. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi.org/10.1016/j.cbpra.2011.01.001
  7. Chung D, Hadzi-Pavlovic D, Wang M, et al. Meta-analysis of suicide rates in the first week and the first month after psychiatric hospitalisation. BMJ Open 2019;9:e023883. doi:10.1136/bmjopen-2018-023883
  8. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 2001;52:6 828-833.
  9. Carter GL, Clover K, Whyte IM, Dawson AH, D’Este C. Postcards from the EDge project: Randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self-poisoning. BMJ, 2005;331:7520 805-807.