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 as ongoing assessment and treatment that you are providing
The preceding list is skeletal. Depending on your setting and needs, to fill in the content, you might elaborate on your rationale for treatment, including describing how and why the treatment you are providing is a good match for your client’s unique problems and symptoms. Specifically, you could (a) highlight immediate or prominent risk factors (including suicide triggers) and how you are addressing them, (b) describe how you plan to draw out or activate protective factors to reduce suicidality, and (c) include immediate and longer term interventions you are taking to reduce suicide risk. Using direct quotes or paraphrases from your client that support your evaluation and decision-making is recommended. You can also include mental status observations of physical and nonverbal behaviors, such as lack of eye contact, sighs, or poor hygiene.
Competency 9: Know the Law Concerning Suicide
The laws concerning suicide are simple and complex. The simple part follows court rulings on the duty to protect clients from knowable dangers from self and others (Tarasoff v. Regents of the University of California, 1976). The duty to protect is a legal mandate.
In addition to knowing federal guidelines regarding suicide and the law, you also need to know laws and statutes in your specific locality. Jobes and O’Connor (2009) wrote, “All states . . . have explicit expectations of a duty to protect . . . when [clients] pose an imminent danger to self” (p. 165). The state in which you practice has legal statutes covering the involuntary civil commitment process and standards of care for working with clients or minors who are suicidal. Consulting with experienced professionals in your region (and/or seeking training) can help you understand the practical steps you need to cover in your locality.
If you are employed by an agency or school, you will need to know its suicide policy. When you join a new agency or school, read the institution’s suicide-related policies and procedures and discuss them with a senior clinician or administrative staff before you even begin seeing clients or students. If your agency or school does not have suicide-related policies and procedures, work with your administration to adopt a temporary working model from a similar agency, and establish a task force to create a more permanent model. You never know when the next client or student will be suicidal. On the first week of his first job, one of our graduates had to manage a student who was actively suicidal. He called and said, “Wow! You guys weren’t kidding when you said to know how to handle things before you even open the door!” (see Wheeler & Bertram, 2019, for more information on legal issues in counseling).
Competency 10: Engage in Debriefing and Self-Care
Feeling responsible for life-and-death situations is overwhelming (Cramer et al., 2013). As in the opening case of Kevin, when clients make suicide attempts or die by suicide, practitioners often experience an avalanche of guilt, preoccupation with possible mistakes, and feelings of incompetence. Even though such feelings are natural, they are still extremely difficult. As noted in Chapter 1, self-care is always important for mental health and school professionals, but when suicide is the issue, self-care is especially critical (Binkley & Leibert, 2015).
Debriefings of some sort are important