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Determination of Risk and Intervention


This section focuses on level of risk as determined by the presence and combination of risk and protective factors and subsequent intervention information. In determining risk and interventions, it is important to consult knowledgeable colleagues.

***Counselors-in-training are highly encouraged to seek consultation with supervisors or instructors if there is immediate concern regarding a client.


Assessment and Determination of Risk

See Procedures for Assessment of Suicide Risk for assessment procedure examples.

Although there is much information to gather, there are no shortcuts to suicide assessment. Knowledge of risk factors and protective factors is essential in assessment of suicide risk. None of the warning signs (risk factors), if found in isolation, should cause you to be concerned, however the combination of several signs should prompt you to take several steps.

Part of decision-making involves evaluating whether protective factors outweigh risk factors or vice versa (Brems, 2000). As part of this evaluation it is also imperative that the counselor consider whether this balance is stable or if it may change in the future. For instance, if a mother has a strong protective factor related to being there to raise her daughter, but the daughter is 17 and about to graduate from high school and leave for college, the balance may then shift.

Risk may be judged by considering the following factors:
  1. the degree of psychological disturbance
  2. suicidal intent by self-report and objective evaluation
  3. the particular suicidal behavior exhibited
  4. ethality of plan/method selected
(Brems, 2000)
 In addition, the following issues could also be considered:
  1. imminence of the behavior (from likely never to occur immediately)
  2. clarity of danger (from vague or no time, place, method, and opportunity)
  3. intent (from no wish to die to strong wish to die)
  4. lethality of behavior (from non-lethal method to highly lethal method)
(Brems, 2000)


The assessment of risk is not based on a strict formula.

In general, LOW risk would indicate the presence of ideation or passing thoughts without a plan and means, etc. MODERATE risk would indicate a serious consideration of harm, ideas of a plan and means, no access, the existence of some support, some risk factors present. HIGH risk would indicate the details in the plan, the greater degree of lethality and strength of intent combined with presence of risk factors and absence of support.

Immediate Predictors

Low Risk Moderate Risk High Risk
Method Undecided Decided Decided
Means Not present Easy access In possession
Time and Place Not chosen Tentative Definitely chosen
Lethality Low Moderate High
Preparation None made Some planning Steps taken
Prior attempts No Yes Yes

Life Events or Conditions

Low Risk Moderate Risk High Risk
Trigger (or trauma) None or mild 1 or moderate stress Several or severe traumas

Psychiatric History

Low Risk Moderate Risk High Risk
Diagnosis No diagnosis 1 diagnosis Multiple diagnosis
Severity None Moderate Severe
Discharge More than 12 mts More than 3 less then 12 mts. Within 3 months
Substance Use None History of use – intermittent use Currently using
Physical illness and pain Mild or none Chronic or moderate Chronic or Severe
Loss No or unimportant loss One loss Multiple losses
Family suicide history No member One member Multiple members or close member or recent

Emotional or Behavioral Factors

Low Risk Moderate Risk High Risk
Hopelessness Mild Moderate Severe
Impulsivity Low Moderate High
Perception of current emotional state Will pass or be able to work through Unsure if it will pass Inescapable and intolerable
Problem-solving skills Generally good Adequate Impaired
Future plans Yes Unclear No

Social Supports

Low Risk Moderate Risk High Risk
Number available and identifiable Adequate resources Limited resources No resources
Willingness to use Willing to access Limited willingness Unwilling
Connection with others Regular social contacts Some social contact
Isolated and withdrawn

This grid provides an example of how to organize the information you collect in your assessment. There is no substitute for your clinical judgment that is based on experience, best practice, and consultation with other professionals.


Intervention

Dealing with suicidal clients becomes a management issue first, not a therapy issue. The most important step is keeping the client from hurting him/herself or someone else. The legal guidelines state: If there is clear and imminent danger of a person harming him/herself and/or others, the counselor must take reasonable personal action or inform responsible authorities. Consultation with other professionals must be used where possible. At times it may be difficult to assess “clear and imminent,” however, it tends to be better to err on the side of caution rather than risk negligence.

In many cases, the counselor can work with a client, distress can be decreased, and mutually agreed upon action can be taken. Of course, the counselor cannot rule out the necessity for directive action. If a client is suicidal, the counselor needs to operate from a crisis intervention (LINK TO CRISIS SITE) approach. Meaning that the counselor becomes more active, directive and problem solving oriented, while continuing to demonstrate respect for the client.


Counselor skills and behaviors

Important skills, attitudes and behaviors when working with clients in crisis or with suicidal ideation:
Calm and controlled Exhibiting respect for the client Problem-solving skills

Active listening
Trustworthiness Restatements
Sincere Directive Reflections of feelings
Empathic Cognitive disputation Challenging and confrontation
Contract development Ability to involve client in making decisions and contributing to problem-solving  

In general, the approach to working with suicidal clients is to move from least restrictive and client empowering to highly restrictive. For example, moving from an outpatient confidential intervention, to outpatient management that involves others (in cases with children and adolescents – caregivers should be told of potential for suicide), to voluntary and finally involuntary treatment if other options did not work (Brems, 2000).


Potential actions/interventions

Action Example Goal
Make psychological contact Invite client to talk; Listen for what happened and clients perceptions; Use restatements and reflections to convey understanding and support Client to feel accepted, heard and understood; reduction of intensity of emotions
Assessment See Procedures for Assessment Determine client needs, risk, protective factors; Learn about what is important to client
Identify the message What will committing suicide do for you? What problem will it solve? Determine what the client is attempting to communicate or the problem that will be solved
Define and impose goals We need to come up with some things we can do that will help you… Move into problem-solving
Expand client’s view of problem and situation
     
  • While suicide may be one option, it is also irreversible – let’s consider other ways to…
  • I see what you are saying, but I also wonder if this is another way to look at it…
  • You say “nobody would care” but I hear you talking about your nephew with great affection, it sounds like you care for him…
Increase choice options; Reduce tunnel vision; Improve reality testing
Build on strengths Point out client’s ability to tolerate pain
Point out client’s coping abilities
Improves cognitive functioning and improves reality testing
Support client problems solving Separate thought from action
Reinforce expressions of affect
Consider consequences of action
Engages client in active problem solving
Safety Contract “As part of our work, I would like for us to develop a no-harm contract…”
“It is important to involve the client as much as possible”
Client pact not to commit suicide while in treatment
Remove Means
  • If means are present – confiscate
  • Can be included in contract
  • May need to involve others to assure removal
Reduces potential for impulsive act
Engage social support
     
  • It is best (when possible) to get client’s permission and guidance as to who to involve
  • When involving others – counselor needs to educate and support these people and discuss their role with the client
  • Balance client confidentiality needs and safety needs
  • CHILDREN AND ADOLESCENTS – counselors have duty to inform parent/guardian
  • Can help with removing means
  • Supervise client
  • Provide assistance and general support
Increase sessions/contacts
  • Shorter time period between sessions
  • Calls or check-ins between sessions
  • Provide emergency contact information, hot-line numbers, etc
Provide consistent support during period of greatest need
Voluntary hospitalization
  • If client agrees – begin process immediately
  • Continue to involve client as much as possible
  • Consider transportation to facility
  • Local procedures need to be followed
Prevention in high risk situations
Involuntary hospitalization
  • Local procedures need to be followed
  • Continue to involve client as much as possible
  • Bring documentation (organized information) regarding client assessment, diagnosis, and risk
Prevention in high risk situations when client is “uncooperative”

Remember to document assessment, decision-making, and intervention information.