In my previous posts, I outlined risk factors and how to evaluate suicide risk. In this post, I will discuss how to make a decision regarding a suicidal client.
Here is one decision-making model. This model views risk as ranging from “nonexistent” to “extreme.”
Nonexistent: no ideation or plan
Mild: ideation, no specific plan, some risk factors
Moderate: ideation, general plan, risk factors but a reason to live, self-control intact
Severe: frequent/intense ideation, specific plan, lethal and available method, many risk factors and little control
Extreme: same as severe but with specific intent
The first category is of no immediate concern, the second two we should follow-up with more intense outpatient treatment, and the last two categories we probably want to hospitalize or commit. As mentioned earlier, decision making with regard to suicide is a very subjective process, and will depend both on the client’s unique characteristics as well as counselor characteristics. Don’t forget to seek supervision and/or consultation with peers.
Suicide Contracts
Although many practitioners do not distinguish between them, there is a difference between a suicide contract and a safety plan. Basically, a suicide contract states that the client agrees not to hurt him or herself, whereas a safety plan outlines resources and coping strategies for the client. Often practitioners combine these. Both are handwritten collaboratively in the session and signed by both the client and the therapist. If client refuses to sign it’s somewhat of an indication about their intent, and should be considered a risk factor.
Research suggests that clients do not benefit from suicide contracts, whereas safety plans are helpful. The reason clinicians use suicide contracts is usually to protect themselves legally. For those reasons, suicide contracts will not be discussed further.
Safety Plans
A good safety plan documents the client’s understanding of warning signs, possible coping strategies, how to connect with others for support and distraction, which family members or friends to contact for help with current crisis, which mental health agencies/resources are helpful, and ensuring or creating a safe environment. The counselor creates all of this information with input from the client. The plan is then presented to the client, who can post it in a prominent place as a reminder and useful resource.
Documentation
Documentation is very important with regard to suicide assessment. Basically, everything should be recorded; even things that client denies, like intent. It is important to document that the question has been asked and answered. The documentation is proof that a thorough suicide risk assessment has been conducted, relevant historical information was obtained, previous treatment records were reviewed or requested, direct evaluation of suicidal ideation occurred, one or more professionals were consulted, limits of confidentiality were discussed with client, appropriate resource information was provided to client, and authorities and family members were contacted as required by law. This documentation should be maintained as part of the psychotherapy record.
Yours in the Joy of Knowledge,
Dr. Barbara LoFrisco
Source: personal communication, Dr. Caroline Wilde, November 13, 2013
