After decades in the psychotherapy trenches, I’ve come to believe the issue of suicide is something that will remain a clinical mystery, much less ever be solved. The most recent numbers released by the CDC reveal 48,000 people succumbed to suicide in 2018, and since 1999, the suicide rate has risen 35 percent.
So if you’re working with a client who either speaks of suicide or seems serious about wanting to take some life-ending measure, what does an adequate evaluation look like, and how do you go about documentation?
The Evaluation Process
First, you want to record that you’ve done a first-rate evaluation, not merely conducted a cursory checklist. A quality assessment should cover important risk factors, indicate that you sought whatever corroborating information was available, and that your gave careful thought to your client’s current suicide risk. Documentation will be your go-to ally if a completed suicide were to unfortunately occur. The golden words when charting are “suicide risk assessment,” followed by a narrative indicating that the evaluation you conducted was thorough. By all means, don’t simply state, “patient denies suicide ideation.” Clients lie about suicidal issues frequently.
Due diligence efforts that should be documented when assessing a client’s level of risk pursuant to preventing suicide include: “Examined client’s thoughts regarding death;” “talked considerably about his inclinations to end his life;” “discussed the loss of his father to suicide.” Then note your impressions and indicate what action(s) you decided upon to best protect the client. “The client’s risk for suicide is moderate, but not elevated enough such that hospitalization is imminent,” or, “I addressed my concerns with his spouse and she will join us for tomorrow’s session.”
If you believe a client needs immediate protection, place a call to local authorities and ask them to come directly to your office. Then document accordingly, “addressed the need for hospitalization at this time with the client and spouse, and we are setting up transfer to the nearest emergency facility.”
No-suicide Contracts
I have long opposed such contracts. From a suicide prevention standpoint as well as from a liability perspective, no-harm pacts are worthless for at-risk clients because you can’t rely on them as a safety measure. To be clear, I’m not denigrating their use within the context of the therapeutic alliance – when you’re working closely with a client, it’s important to have certain “agreements” in place, particularly when it comes to harm-related factors. But they must not be relied upon as an instrument to protect a client’s life, nor should they substitute for appropriate monitoring and physical protective measures.
Major Suicide Risks
Some issues are so acute that once they present themselves, it should prove difficult for a client to convince you that he or she is not at high risk for suicide. Factors such as recent suicide attempts, threats of suicide made by very depressed or psychotic clients, and erratic, unpredictable behavior are all obvious red flags. However, each client is different in some respect thus evaluation will never be a one-size-fits-all process. Another significant risk factor is client instability. For example, after a few days of close monitoring associated with a hospital stay, a client’s “improvement” may not be either real or reliable and thus a red herring, so be sure to evaluate the client’s vulnerability to whatever environmental circumstances they may encounter in upcoming days. The unpredictability of suicide always means we have to take responsibility for handling risk seriously.
Protective Factors
By protective factors, I’m referring to the client with suicide issues who has a supportive family, a good job, or anything else of a positive nature going for them. You want to document these, but be aware that when it comes to determining serious suicide risk, they’re basically useless, because a severe depression or something of an overwhelming nature can override positive supports rather quickly. People who are consumed by despair, pain, and intense anguish just don’t focus on anything else but their demise. Alternatively, advancing the benefits of protective factors can be very helpful when you’re engaged in suicide counseling with those at lower risk.
Poor Documentation
The worst example of poor documentation is recording a simple “no suicidal ideation” comment, without offering even a brief narrative indicating suicide risk was examined. Such a perfunctory notation implies – whether actually true or not – that the clinician gave but a superficial look to a possibly serious matter and the assessment may have been slapdash.
HIPPA Regulations
If I’m working with a client whose life may be in danger, the last things on my mind are HIPPA and privacy concerns. Yes, suicide-related lawsuits are common, but the overall number of these directly related to confidentiality breaches is very low in such situations. When you’re acting with the best of intentions, juries understand that talking with a client’s spouse or relatives who know the client well is crucial when the client’s life is in peril.
The suicidal client is one of the most daunting issues we face as clinicians, so thorough evaluation, assessment, and documentation are your best friends. Good faith judgments and efforts will minimize the chances that you’ll be second-guessed if the situation becomes litigious.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.