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A few years ago the topic for my masters research project was prompted by my interest and concern about the impact of stress on clinicians when managing risk of clients vulnerable to suicide.
Recently circumstance has turned my attention once again to the stressful business of assessing and supporting clients who are at risk of suicide. This is undoubtedly one of the most difficult aspects of any therapists work and the costs of getting it wrong are very high for everyone involved.
Ultimately when a client indicates to us that suicidal thoughts and urges are becoming a serious risk to them, they are putting the responsibility for their life in our hands. We are then legally and morally obliged to use our clinical expertise to inform the action we take to ensure their safety.
The following are practical tips for keeping your self and your clients safe:
Safe foundations
1. If you work in an organisation make sure you are familiar with the procedures around managing a client who is vulnerable to suicide. (if you don’t follow procedure you can not rely on your organisation to support you and you may face disciplinary or legal action)
2. If you are working in private practice create and document your own procedures to support you when clients are becoming vulnerable to suicide. It is very difficult to think well when under stress, especially if you have never faced the situation before.
3. Keep a list of crisis lines and local CAT teams for your own reference and to give to your clients.
4. Assess your clients well at the beginning of your therapy especially around past suicide attempts or ideation and loved ones lost through suicide. These questions may seem hard to ask a new client but they are essential for everyone’s safety.
5. Make sure you have the phone number and address of the clients you work with so that if you need to call the police to do a welfare check or ask the Adult Community Services (ACS) team to visit you know where to send them.
6. Ensure you have the name, contact details and consent to contact at least one friend or family member who has agreed to support your client in an emergency.
7. Create a crisis plan with your clients when they are feeling well if you suspect they will require it. (they will not be able to do it when suicidal ideas have a grip on them)
8. Your client’s safety needs to take precedence over your therapeutic relationship.
You can avoid confusing conflicts by informing your clients at the beginning of therapy that if they reveal that they are going to harm themselves you will do what it takes to ensure their safety.
9. Give yourself plenty of time between sessions if you have any indication that someone is vulnerable to suicide. (The last thing you need is to be in a rush with decision making)
Know what you are listening for.
1. Many people experience suicidal thoughts as an escape from the pain of their existence. Some people live with daily (chronic) suicidal ideation. There is a significant difference between thoughts about suicide and making plans about it with an intention to die.
2. Sometimes clients will try to backtrack and say that they are ok when they see that you are taking action to ensure their safety. If your clinical judgment says that the person is at risk do not go back on your clinical decision unless you have document-able evidence to the contrary.
Consult, inform and document.
1. Consult with another clinician and document that you have done so. You can consult via the phone with the triage worker from the adult community services team (ACS) for your client’s local catchment area if no one else is available to you. The ACS provides care previously provided by CAT, CCT, MST and PMHT
Ask for the workers name and document that you have consulted in your notes.
2. Ensure you communicate with other members of the clients treating team if they exist and be sure to keep them up to date with the client’s vulnerability if it increases. Document that you have done so.
3. Write clear, concise notes after the session. Include all and only the necessary facts.
Ensure that anything contained in your notes is factual and clinically observable.
Examples:
X stated “I will attend my GP appointment tomorrow at three”
I informed X’s treating psychiatrist of her increased risk via the telephone at 3pm.
X revealed that he has been experiencing fleeting suicidal thoughts but denies that she has any current plans or intent to harm himself.
Recently circumstance has turned my attention once again to the stressful business of assessing and supporting clients who are at risk of suicide. This is undoubtedly one of the most difficult aspects of any therapists work and the costs of getting it wrong are very high for everyone involved.
Ultimately when a client indicates to us that suicidal thoughts and urges are becoming a serious risk to them, they are putting the responsibility for their life in our hands. We are then legally and morally obliged to use our clinical expertise to inform the action we take to ensure their safety.
The following are practical tips for keeping your self and your clients safe:
Safe foundations
1. If you work in an organisation make sure you are familiar with the procedures around managing a client who is vulnerable to suicide. (if you don’t follow procedure you can not rely on your organisation to support you and you may face disciplinary or legal action)
2. If you are working in private practice create and document your own procedures to support you when clients are becoming vulnerable to suicide. It is very difficult to think well when under stress, especially if you have never faced the situation before.
3. Keep a list of crisis lines and local CAT teams for your own reference and to give to your clients.
4. Assess your clients well at the beginning of your therapy especially around past suicide attempts or ideation and loved ones lost through suicide. These questions may seem hard to ask a new client but they are essential for everyone’s safety.
5. Make sure you have the phone number and address of the clients you work with so that if you need to call the police to do a welfare check or ask the Adult Community Services (ACS) team to visit you know where to send them.
6. Ensure you have the name, contact details and consent to contact at least one friend or family member who has agreed to support your client in an emergency.
7. Create a crisis plan with your clients when they are feeling well if you suspect they will require it. (they will not be able to do it when suicidal ideas have a grip on them)
8. Your client’s safety needs to take precedence over your therapeutic relationship.
You can avoid confusing conflicts by informing your clients at the beginning of therapy that if they reveal that they are going to harm themselves you will do what it takes to ensure their safety.
9. Give yourself plenty of time between sessions if you have any indication that someone is vulnerable to suicide. (The last thing you need is to be in a rush with decision making)
Know what you are listening for.
1. Many people experience suicidal thoughts as an escape from the pain of their existence. Some people live with daily (chronic) suicidal ideation. There is a significant difference between thoughts about suicide and making plans about it with an intention to die.
2. Sometimes clients will try to backtrack and say that they are ok when they see that you are taking action to ensure their safety. If your clinical judgment says that the person is at risk do not go back on your clinical decision unless you have document-able evidence to the contrary.
Consult, inform and document.
1. Consult with another clinician and document that you have done so. You can consult via the phone with the triage worker from the adult community services team (ACS) for your client’s local catchment area if no one else is available to you. The ACS provides care previously provided by CAT, CCT, MST and PMHT
Ask for the workers name and document that you have consulted in your notes.
2. Ensure you communicate with other members of the clients treating team if they exist and be sure to keep them up to date with the client’s vulnerability if it increases. Document that you have done so.
3. Write clear, concise notes after the session. Include all and only the necessary facts.
Ensure that anything contained in your notes is factual and clinically observable.
Examples:
X stated “I will attend my GP appointment tomorrow at three”
I informed X’s treating psychiatrist of her increased risk via the telephone at 3pm.
X revealed that he has been experiencing fleeting suicidal thoughts but denies that she has any current plans or intent to harm himself.
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