and contexts in which employment responsibilities will require you to make your best estimate of client suicide risk. However, because your specific suicide predictions may be incorrect, avoiding over-confidence, consulting with others, and collaborating with clients is recommended.
Sometimes so-called high-risk clients (based on traditional risk and protective factors) can be managed using a detailed safety plan and close in-home monitoring. Historically, these clients were hospitalized—often involuntarily. Although sometimes it is the only option, hospitalization is not an especially effective treatment for suicide, and the period after hospitalization is a time of heightened suicide risk (Large & Kapur, 2018).
Tasks associated with this competency include the following:
1 Recognize that because your ability to accurately categorize risk is limited, no matter the risk level, you should collaboratively establish a treatment plan to maximize client safety. This will likely involve safety or crisis planning (Bryan & Rudd, 2018; Stanley & Brown, 2012).
2 Expand your knowledge of the client (Granello, 2010b). Obtain previous medical/mental health records as well as collateral information from friends, family, or other supportive contacts (Wheeler & Bertram, 2019). This will require client consent; in some circumstances, you may need to breach confidentiality (e.g., when clients are suicidal and refuse treatment, when you have a duty to warn family about elevated risk, or when youth have suicidal ideation or make suicide gestures).
3 When clients will not collaborate on safety planning, or when you are setting mandates, categorize risk using “phraseology such as low, moderate, high, and extreme risk” (Cramer et al., 2013, p. 7). Most experts advise against using a no-risk category.
Competency 6: Develop and Enact a Collaborative Evidence-Based Treatment Plan
Suicide treatment planning should be strengths based and collaborative whenever possible. However, sometimes clients are unable to collaborate. They may be agitated, impulsive, lethargic, unengaged, and/or only minimally responsive. On other occasions, clients will flat out resist your collaboration efforts. When clients are unable to contribute to safety or treatment planning, risk is likely higher, and you will need to take the lead in safety planning.
When clients report suicidal ideation, short-term safety planning is recommended. Two short-term safety planning protocols have evidentiary support. These are Stanley and Brown’s (2012) safety planning intervention and Bryan and Rudd’s (2018) crisis response plan.
Longer term treatment planning is an important part of this competency. As Linehan (1993; Linehan et al., 2012) has discussed, sometimes clinicians need to be bold and direct. She typically speaks frankly, saying things like “We may have to go through hell together.” Her purpose is to show her commitment to the treatment process and to give clients messages of hope (e.g., “I know this therapy I’m offering you can help”). Consistent with general counseling and psychotherapy guidelines, engaging clients in an ongoing treatment plan requires you to present a clear rationale that connects counseling tasks to collaboratively generated counseling goals (J. Sommers-Flanagan, 2015b).
To have competency within this domain, you will need to do the following:
1 Invite clients to collaborate with you on short-term safety planning or longer term treatment planning.
2 Be able to implement specific steps linked to either the safety planning intervention (Stanley & Brown, 2012) or the crisis response plan (Bryan & Rudd, 2018).
3 Become directive, take the lead, and possibly initiate intensive treatment (e.g., a residential facility or psychiatric hospital) when clients are not willing or able to engage in safety planning.
4 Speak to clients about your hope for positive outcomes, your desire for them to commit to ongoing treatment, and the rationale for counseling tasks and goals.
5 Scan for and reflect strengths in your clients’ presentation. This will require knowledge of protective factors and reframing skills (Cureton & Fink, 2019).
Competency 7: Notify and Involve Other Persons
Social isolation is a risk factor for suicide (Joiner, 2005). To address isolation, treatments for clients who are suicidal often involve the recruitment of supportive people, including other treatment or medical providers, friends, family, church or community members, mentors, and others. Involving other people in treatment and safety planning can be a critical component of successful treatment (Cramer et al., 2013).
Ideally you can work with your client to generate a list of people to contact and involve as supporters of treatment. However, if you are working with a client who resists your efforts to identify and establish social support networks, you will need to establish a safety plan without social connections or breach confidentiality and make the contacts. Breaching confidentiality may rupture the therapeutic relationship, but it does not always have that effect. Although your client may discontinue counseling with you, the need for immediate safety sometimes outweighs longer term treatment and relational considerations.
Competency 8: Document Risk Assessment, the Treatment Plan, and the Rationale for Clinical Decisions
Documentation serves several purposes. Writing down your observations, organizing your inferences, and reflecting on decision-making helps you remember your clients’ dynamics and goals. Your notes will provide you with an accurate and efficient method of monitoring client progress or deterioration. Adequate documentation can also mitigate professional liability (Rudd, 2006).
Professional documentation begins with a signed informed consent form that outlines how you work with clients who are suicidal, what clients should do in cases of emergency, and the reasons you would choose or be required to breach confidentiality. You should document everything from case notes to consultations to decision-making rationale. Whatever format you use for intake and progress notes, to help organize your documentation, we offer the following list of items and content to include in your client files (for a comprehensive outline of an intake report, see J. Sommers-Flanagan & Sommers-Flanagan, 2017):
1 Documentation of initial client paperwork, including your client’s signature on an informed consent
2 Previous treatment records
3 Information about your suicide assessment, treatment plan, and decision-making, including the following content:Suicide-related historical information (e.g., suicidal behaviors by family members, client previous attempts, lethality of previous attempts)Assessment of risk and protective factorsSuicide assessment instruments or questionnairesAssessment of suicidal thoughts, plan, client self-control (agitation), and intentA record of consultations with previous counselors and other professionalsYour rationale for the treatment you are providing and your rationale for your treatment disposition and referrals (e.g., day treatment, hospitalization)Any contacts you have made with authority figures (police officers, administrators, teachers, and/or family members)
4 Your collaborative safety plan, including firearms safety; keep a copy in your files and give your client a copy (If your client reports suicidal ideation and you do not create a safety plan, you should document your rationale for not creating one.)
5 Notes on any review or update of the informed consent and the crisis or safety plan
6 Progress notes that include your client’s response (e.g., progress, resistance, deterioration) to your initial suicide assessment as well
