Safety Assessment and Crisis Intervention in Private Practice: Part I
By Chris Campassi
As a therapist, your primary goal is always to work with clients in a way that will best facilitate their growth and attainment of their treatment goals. However, as licensed professionals, we are also tasked with protecting clients from harming themselves. We also need to protect the community from a client who may become violent, aggressive or even homicidal. Balancing these duties to community and client can be tricky to navigate, as you do hold some level of liability in the decisions you make.
If you are a therapist in private practice, it is important to be prepared to intervene in a client crisis when necessary. Because crisis intervention happens far less frequently in private practice than in an agency setting, it is easy to forget the process, which can lead to anxiety when a crisis arises.
In this blog series, I will touch on how to work with clients who are actively suicidal or engaging in self-harm, how to assess and discern when a client meets the criteria for an involuntary hold or inpatient treatment, and the steps to take to ensure supervisees can help their client get the treatment they need, in the safest way possible.
Assess Your Own Beliefs About Safety Risks and Suicide
Before you can develop the skills to assess safety risks, it is important to honestly assess your own feelings about suicide, and your comfort level in talking about suicide with clients. A therapist who is uncomfortable with the idea of suicide, or one who has specific beliefs against the idea of suicide will likely avoid talking about this with clients. In doing so, the client may infer messages that this is not something they can talk about in therapy.
Similarly, some therapists who do not feel comfortable with these conversations will err on the side of caution, and may initiate hospitalization with liability in mind, instead of the overall wellbeing of the client.
If you feel uncomfortable with talking about suicide or just lack the confidence, I would recommend discussing this in clinical supervision if you are a pre-licensed therapist, or in clinical consultation if you are already licensed and just need some support in this area.
Working With A Suicidal Client
Assessment for suicide, self-harm, homicide, or violence begins in the initial intake. It is critical that you take the opportunity during intake to assess for any history of suicidal ideation, suicide attempts, acts of aggression or violence, and past hospitalizations. In doing so, you gain important information that will inform future decisions, and also normalizes conversations about suicidal ideation and homicidal ideation.
Once you have completed the assessment, it is important to note any concerns with safety that should be included in the treatment plan. Suicide prevention experts (Freedenthal, 2018) recommend that suicide prevention be a specific treatment goal when a client has active suicidal ideation or recent suicide attempts. In doing so, you and the client commit to assessing for suicide or other risky behaviors during each session.
By normalizing the conversation about suicide, you are providing the client an opportunity to openly explore their feelings. This has been shown to reduce the likelihood of acting on these thoughts. The ongoing conversation also provides you a sense of the client’s baseline thoughts.
Having a clear baseline allows you to recognize when such thoughts have escalated to a point in which the client may act on these thoughts. Much of the art of assessment for suicide and homicide is being able to recognize significant changes in client presentation and report that may indicate a heightened risk of an attempt. Without a baseline understanding of the client, you cannot determine if the current report of thoughts is concerning. Getting support for your compassion fatigue and burnout from someone who is local.
Legalities of Involuntary Commitment
It is also important to understand clearly the legal components of an involuntary commitment for treatment. In the event you determine a client is at imminent risk of harming oneself or others, it is your duty to intervene and ensure that the client and community are safe.
All states outline the requirements and process for initiating an Involuntary Commitment for further evaluation. These laws allow a therapist (and other designated professionals) the authority to initiate an involuntary admission to an emergency department or hospital to be evaluated for possible inpatient psychiatric hospitalization for further treatment.
Note that each state uses different language when referencing the Involuntary Commitment process. For example, you may hear terms such as “72-hour hold”, “petition for involuntary commitment”, or your state may refer to the name of the actual statute that outlines the process (i.e., the Baker Act in Florida, or 27-65 in Colorado).
The legal requirements to initiate an involuntary hold for further evaluation are outlined in each state’s legal statutes. Because each state can vary significantly on definitions as well as the procedures to initiate a hold for further evaluation, it is recommended that you review and understand your state’s specific laws and the language used in the statute. This will benefit you in using this language when you initiate or recommend an involuntary hold.
Suicide and Homicide Assessment
As I begin to talk about assessment of suicide or homicide, I want to acknowledge that I have mostly referenced suicide assessment thus far in this blog. I have done this intentionally. While the process and language for initiating treatment for suicide and homicide are very similar, I do find that working with a suicidal client and potentially violent client can be very different.
While you want to work openly with a client who is experiencing suicidal thoughts, in a way that is empowering and avoids an involuntary admission for treatment, you cannot work in the same way with a potentially violent client, as you do hold some responsibility in protecting the community.
Simply put, I am more likely to err on the side of caution when a client is expressing homicidal ideation than when a client is expressing suicidal thoughts.
Ideation, Method, Plan and Intent
Many of you have likely heard these terms during your education and through practicum and internship. If you are consistently working with clients who require high-risk intervention, you probably have a clear idea about what each term means and how it relates to decision-making when it comes to crisis intervention.
However, many of you probably learned about this a long time ago, but have never had to intervene in a crisis, or it happens so infrequently that it is difficult to hone these assessment skills. For you, I want to provide a brief review of these terms and how they impact the crisis assessment and intervention process.
Ideation – When we use the term ideation, we are referring to the “ideas” or thoughts a client may have regarding suicide, homicide or violence. This is typically the first sign that a client may be at risk of harming themselves or others.
However, it is really important to note that having these thoughts does not necessarily indicate that a client will act on them. In fact, research suggests that only 7% of people with suicidal ideation make an attempt (Freedenthal, 2018). Further research also indicates the clients who are able to freely talk about suicide in therapy are less likely to act on these thoughts (Freedenthal, 2018).
All this to say, if a client expresses ideation, this is a cue to assess further, but not sufficient for initiating involuntary treatment.
Method – Once a client has expressed SI or HI, it is important to begin assessing for risk that the client may act on these thoughts. The first question you might ask is if the client has thought of ways they might kill themselves, using direct and specific language. If a client has identified a method, ask them about their access to that method. Increased access to their method of choice increases the risk of acting on these thoughts.
Likewise, a method that a client does not have access to reduces the likelihood of acting. A common example is someone stating that they would shoot themself, but does not have access to a firearm, has never fired one, and generally does not know the process of buying one. In this case, the method sounds scary, but the access is minimal and not indicative of increased risk.
Plan – While it is really important to assess the method and access to that method, it is also important that you assess further whether or not the client has begun to take any steps to access this method or to begin planning for an attempt.
Many people will tell you they have thoughts of overdosing and have easy access to pills (generally speaking, everyone has access to medications that could cause harm, as we can all go to the store to buy Tylenol, a very lethal medication taken in high doses). However, this does not mean they plan to act on these thoughts. You will need to assess planning further.
As you assess planning, ask the client to share any steps they have taken to prepare for a suicide attempt. Some steps that clients may take are:
- Buying a gun
- Stockpiling pills for an overdose
- Buying a rope and tying it into a noose
- Give away their belongings
- Change their will or life insurance
- Start to write notes to loved ones
Finally, and often most concerning, a client may begin to “practice” how to harm themselves.
Intent – After assessing for any plans or steps a client has taken, begin to ask the client about their intention in acting on these thoughts. An easy way to assess this is to ask the client how likely they are to act on these thoughts when they leave the office today.
Some clients can clearly state that while these thoughts are looming, they have no intention of acting on them, and in fact may definitively say “I would never do that because….” and will give you reasons they would never do this. Reasons could include not wanting to hurt their spouse or children, or spiritual beliefs that prohibit such action.
Other clients may state that they have every intention to act on these thoughts, or that they do not feel confident that they will be able to restrain themselves from acting on these thoughts. And some clients will just state that “they do not know” or that they have no intention but worry that in an impulsive moment they will act on these thoughts.
Risk Factors and Protective Factors
In addition to assessing the above signs of suicide, it is also important to consider risk factors and protective factors in making any decision. Please note that one must distinguish between the “signs” that someone may be at risk, which are the above factors, as well as the risk and protective factors.
It is important to understand, however, that the risk and protective factors do not in themselves indicate risk of acting on suicide. Rather they, either enhance or mitigate that likelihood. Below are some risk factors and protective factors to consider:
Risk Factors:
- Impulsivity
- Hopelessness
- Increased anxiety or poor self-regulation
- Substance abuse
- Cognitive Impairment (Dementia, TBI, Stroke, etc)
- Gender – Males more likely to complete suicide
- Age – Older adults or teens
- History of attempts
- Family or Friend has completed suicide
- Identification with marginalized or oppressed group (i.e., LGBTQ+)
Protective factors:
- Hopeful and Future-Oriented
- Social Support (Family and Friends, Co-workers, classmates)
- Financial Resources
- History of treatment or recovery
- Self-awareness and insight
- Access to general Healthcare
- Long-standing rapport with therapist
Grave Disability Assessment
Thus far, I have focused on SI and HI assessment, as these are the most common presentations that lead to involuntary treatment. However, many states also include “grave disability” as a factor that can be assessed for involuntary commitment.
The term grave disability refers to a client that is entrenched in acute mental health symptoms that prevent the client from having the capacity to make decisions that will keep them safe, or cause them to behave in ways that could lead to severe harm or death. An example might be a person experiencing hallucinations telling them they can fly, which could lead to jumping from a height that could cause grave physical harm.
In assessing for grave disability, it is important to be able to clearly assess the symptoms the client is experiencing. In addition, you want to ask about any past diagnoses that support that these are the symptoms causing the concerning behavior, and how these symptoms place the client at risk of harming themselves, either intentionally or inadvertently.
When documenting an assessment for grave disability, be clear about all of the symptoms the client is experiencing. Then you want to connect how these symptoms prevent the client from being able to meet their basic safety and security needs, as well as the imminent risk that the individual could harm themself or others.
In your documentation for grave disability, it is not enough to state the symptoms, no matter how erratic or bizarre they may be. People do have the right to remain psychotic, so you will need to make the case that the symptoms put them at risk of harm to self or others.
Emergency Department Evaluation and Inpatient Hospitalization
Once you have determined that a client is in need of further evaluation for Inpatient Psychiatric admission, you will want to initiate the process of writing the involuntary commitment, getting transportation in an ambulance to the emergency room and following up with emergency room staff to provide collateral information.
Understanding the sequential steps of this process will not only help you in the moment you need to initiate a hold, but will also allow you to explain to your client what to expect during the process.
If you are interested in learning more about safety assessment and crisis intervention in private practice, check out upcoming training on this topic: Risk Assessment & Safety Intervention Training
References:
Freedenthal, S. (2018). Helping the suicidal person: Tips and Techniques for Professionals
Community in Private Practice
Here at Firelight Supervision, we are building a space of community and support for YOU! We offer virtual consultation groups as well as individual consultation. We have several Approved Clinical Supervisors that you can choose from, or you can work with several different supervisors. You have the option of either rotating supervisors to meet your current needs, or by seeing one individually and one in a consultation group. Our clinical supervisors are all unique in their style and modalities, so you can find someone that you can connect with and can meet your clinical needs.
And the best part is, everything is virtual, so no need to leave your office and disrupt your own client schedule. You can get the support you need from the comfort of your own office, or home!
How we can help
Sign up for our Burnout Prevention Check-List Email Series. You can also sign up for a free phone consultation to discuss options and learn more about us!
Author Bio
Chris Campassi is an Approved Clinical Supervisor (ACS) and Program Coordinator of Firelight Supervision. He is a licensed psychotherapist in Colorado and North Carolina, blogger, and clinical supervisor for provisionally-licensed and independently licensed therapists. Chris enjoys helping men, medical professionals, and former athletes manage their anxiety and stress so they can live fulfilled and balanced lives. Follow Firelight Supervision on Instagram and Facebook.
