When Should a Risk Assessment Be Conducted?
By Chris Campassi
For therapists, determining when to conduct a formal risk assessment can be difficult at times. You want to be careful that you are not overly focusing on risk as a way to manage liability at the expense of providing support for your client. However, the first thing to do if you are unsure is this: If you are considering doing a risk assessment, you should probably trust your intuition that there may be some risk – go ahead and conduct the risk assessment.
Below I will outline some of the different clinical scenarios that indicate the need for a risk assessment in outpatient therapy.
Risk Assessment During Intake
Most of you probably know that you will always want to do a risk assessment at the initial intake session, but sometimes it may feel uncomfortable. It may feel unnecessary based on the client’s answers to intake pre-screens, or the client may have so much they have to say in the intake that you feel hesitant to stop them and focus on something they may not see as a priority.
Regardless of any of these dynamics, be sure to do a risk assessment. For one, it really is your responsibility as a therapist to begin conversation with the client about suicide, and therapists do take on some liability with these risks. While I caution you not to be too liability conscious, at the expense of treatment, it is important that you protect yourself.
Most importantly, a client may be very anxious about revealing any thoughts of suicide or homicide they are having. They may not know how to talk about it or what to say. Conducting a risk assessment in a way that normalizes how to talk about suicidal thoughts will help the client understand the criteria therapists look for, while also helping them feel more comfortable with these very normal thoughts and feelings.
Finally, conducting a risk assessment at intake will provide you with a baseline understanding of the client’s current thoughts and feelings. It will also give you information about any history of thoughts or attempts, and any history of hospitalizations, all of which will inform you on how your client thinks about suicide. This will help guide you on how to work with the client, while also helping you judge any drastic changes that may indicate increased risk of acting on these thoughts.
Ongoing Assessment
If a client has indicate during intake that suicidal or homicidal ideations are something they struggle with, you should include this a treatment plan goal. As such, if it is a treatment plan goal, it should be addressed regularly in sessions. The frequency of risk assessment should also be indicated as an objective in the treatment plan goal.
Some clients may need a risk assessment during every session, while others may benefit from a once monthly assessment, as well as an assessment when circumstances indicate, as addressed below.
Once again, the more you can talk openly about common risks with your client, and the more they understand the criteria for intervention, the more open they are likely to be with expressing their thoughts. Helping a client understand that talking about scary thoughts can reduce the likelihood of acting on them.
Naturally, anytime a client expresses suicidal or homicidal ideation in session, a risk assessment is indicated. With clients who express chronic ideation, this assessment may be brief. In these cases, be sure to explicitly ask about method, plan and intent, even if the client regularly expresses ideation without method, plan or intent.
Assessment After an Attempt or Self-harming Incident
Anytime a client reports an attempt or an incident of self-harm, a risk assessment is indicated. A client may try to gloss over a situation and tell you that this was a fleeting moment or that they are “fine now”, and indicate they do not want to talk about it.
A client who has made an attempt or is engaging in self-harm is statistically at higher risk of acting on any thoughts they may be experiencing. Therefore, it is important to ask the difficult questions and gain clarity on where they are with regard to thoughts, methods, planning and intent.
It is also recommended that treatment plan goals be re-evaluated after such an incident. If the client does not have a goal related to these risks, it is recommended that you add a goal to the treatment plan and indicate a plan for assessment ongoing.
Assessment After a Traumatic Event, Loss or Friend/Family Completing Suicide
When a client reports to you a traumatic event in their life, it is a good idea to ask if they have experienced any suicidal thoughts. When a client is experiencing a crisis or loss, you will want to help them understand the grieving process, including the possibility that they may experience suicidal thoughts.
When a client has had a close friend, family member or spouse make a significant attempt, or complete suicide, your client’s risk of suicide increases statistically as well. It is unclear why this is the case, but research does suggest an increased risk, and therefore, a need to do a risk assessment.
In these cases, a client who has never had such thoughts may not know how to verbalize these thoughts or talk about them. They may feel shame for having these thoughts as well. Conducting a risk assessment will allow you to check in on any thoughts they may be having, but also will begin normalizing talking about suicide.
Risk Assessment Consultation and Trainings
If you work in private practice, you may not be exposed to as many crisis situations as if you worked in an agency or hospital setting. It is important that you stay sharp with these skills so that you can be prepared when faced with a client who is feeling suicidal or homicidal.
Here at Firelight Supervision, we offer individual consultation as well as trainings for group private practices who want to be prepared for crisis situations and who want to sharpen their assessment skills. If you are one of these therapists, reach out and see how we can help.
How we can help
If you have any questions or want to learn more, feel free to reach out to 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.
