Beyond Checklists: Why Attachment-Informed Suicide Risk Assessment Matters for Clinicians
Suicide risk assessment tools like SAFE-T and the Columbia-Suicide Severity Rating Scale (C-SSRS) are widely used in clinical practice—but are they enough? While these checklists help clinicians triage immediate danger, they often miss a critical dimension of suicidality: the underlying attachment wounds that drive chronic despair.
In this article, Kate Edwards, a licensed psychologist specializing in trauma and relational health, explores why integrating attachment theory into suicide risk assessments offers a more compassionate, accurate, and practical framework for care.
The Inherent Limitations of Traditional Suicide Risk Assessments. Structured tools like SAFE-T and the C-SSRS prioritize measurable indicators—such as suicidal ideation, past attempts, and access to means. While these markers are essential for identifying acute risk, they leave out the client's relational history, emotional isolation, and longstanding feelings of shame or rejection.
Traditional models often:
Emphasize observable behaviors over internal emotional experiences.
Clients may feel impersonal or formulaic when interacting with someone in deep emotional pain.
Focus on short-term stabilization (e.g., hospitalization) rather than long-term healing.
Overlook attachment-related distress, which frequently underlies suicidality.
This approach can leave clients feeling unseen or misunderstood—further compounding their distress and reinforcing their belief that connection and understanding are out of reach.
Attachment as a Core Driver of Suicide Risk
Attachment theory offers a more nuanced view of suicidality. Research shows that the majority of suicidal individuals are not only in immediate crisis—they are suffering from chronic relational wounds.
A study analyzing responses to the Suicide Status Form (Jobes & Mann, 1999) found:
22% reported relational disconnection
20% felt a lack of purpose or belonging
15% cited shame, guilt, or burdensomeness
These findings emphasize that suicide risk is not just about danger—it is about disconnection, rejection, and the absence of secure attachments.
Attachment-Related Risk Factors in Suicide Assessment
An attachment-informed suicide risk assessment highlights deeper, chronic sources of pain that traditional tools may overlook. Clinicians trained in this approach consider:
History of trauma, neglect, or abandonment
(Schore, 2003)
Chronic interpersonal conflict or instability
(Liotti, 2004)
Perceived burdensomeness and low self-worth
(Joiner, 2005)
Hopelessness due to social isolation
(Cassidy & Shaver, 2016)
These patterns are often rooted in early attachment experiences and shape how clients respond to distress, seek (or avoid) help, and perceive their value in relationships.
Attachment-Related Protective Factors
Attachment theory also guides us toward relational interventions that protect against suicide. While traditional assessments often focus on crisis management, an attachment-informed model nurtures long-term protective factors, including:
Strong, secure social support systems
(House et al., 1988)
A sense of belonging and relational worth
(Van Orden et al., 2010)
Willingness and ability to seek help
(Bowlby, 1988)
Effective emotional regulation through secure attachment
(Fonagy et al., 2002)
When clients feel deeply known, valued, and supported, their capacity to tolerate distress—and reach for connection—increases significantly.
Moving Toward an Attachment-Informed Framework
Integrating attachment theory into suicide prevention involves more than just adjusting current tools—it necessitates a paradigm shift in how we assess, understand, and support clients in suicidal distress.
Here are four ways clinicians can begin using an attachment-informed lens:
Ask relational questions
"Who do you feel safe with?" or "What happens when you reach out for support?"
Explore attachment history
"Did you grow up feeling comforted when you were upset?"
Assess chronic isolation patterns
Look for longstanding avoidance, rejection sensitivity, or relational trauma—not just immediate ideation.
Strengthen relational buffers
Help clients build, recognize, and trust in secure relationships, rather than relying solely on short-term safety plans.
Conclusion
Suicide prevention is not just about assessing risk—it is about understanding what makes life worth living. By incorporating attachment theory into clinical risk assessments, we move beyond checklists and into the heart of what clients often need most: connection, attunement, and hope.
For clinicians like Kate Edwards, this shift is not just theoretical—it is deeply personal. It reflects a profound commitment to seeing clients not just as a set of risk factors, but as individuals whose deepest wounds deserve to be met with empathy, insight, and relational care.