Best Practices in Risk Assessment and Safety Planning

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This post is the third in a series for practicing mental health professionals.

As a mental health professional, you know that psychological crises vary widely in form and gravity. Whether a client is dealing with suicidal thoughts or plans to harm someone else, you play a major role in helping them receive appropriate support to cope with life’s most challenging circumstances and move towards regaining a sense of hope and purpose. 

Navigating through a mental health emergency—like helping a client at risk of suicide – can be intimidating and overwhelming – even for professionals. Knowing the proper steps to take may be essential to ensuring the safety of your clients or others. It can also help to alleviate your own stress while de-escalating a difficult situation.  

Research has shown that risk assessment and safety planning are critical components of evidence-based interventions targeting suicidal behavior (Wenzel, Brown, & Beck, 2009; Stanley, et. al., 2009) and have been identified as best practices by the Suicide Prevention Resource Center (SPRC). Intervening in crisis situations can be vital to the outcome. Understanding the important elements of supporting clients who are at imminent risk of harming themselves or others can help you deliver the best care possible. The following evidence-based guidelines involve short-term interventions that can guide you when faced with this sort of emergency.

Communication is key

Practicing clear communication is key to making your client feel heard and understood. This involves more than just listening. It’s important to convey that you’re providing your full attention, both verbally and nonverbally – making eye contact and using empathic, non-judgmental language.

Offering advice or inadvertently minimizing your client’s problems can send the wrong message and create more distance, despair, and hopelessness. Let them know that they are not to blame for what they’re going through and instead, offer your help in a compassionate way. I remember a suicidal client once telling me, “Just having someone to listen to my story makes a huge difference and helps me feel hopeful.”

Asking the right questions

Knowing the right questions to ask to assess a crisis situation is important. Initially, asking direct questions about sensitive topics can feel uncomfortable, but it gets easier with practice. Talking with your client is a proactive step towards increasing safety and decreasing their risk of danger. 

Suicidality and homicidality are assessed in four ways: ideation, plan, access to means, and intent. Ideation includes thoughts and feelings about ending one’s life or the life of someone else. A plan involves ideas about how one might harm themselves or others. Access includes whether or not the client has accessible means to carry out the plan. And Intent includes a desire or motivation to follow through with those thoughts and plan(s). Some questions to assess these risk components might include:

Ideation: “Do you ever have thoughts about not wanting to go on living?” “Are you having thoughts about ending your life?” “Do you ever think about hurting someone else?”

Plan: “Have you thought about how you would hurt yourself or someone else?” “Tell me how you would do that.” 

Access: “Do you have access to _________ [the means to carry out this plan]?”

Intent: “Do you intend to carry out this plan?” “What is the likelihood that you would follow through on these thoughts?” If client endorses intent, ask when: “When would you carry out this plan?”

After asking the right questions, you can gauge your client’s level of risk, and intervene accordingly. Keep in mind how quickly these thoughts and ratings might change throughout the day. 

Risk and Protective Factors

A careful risk assessment is needed to determine if a client is at imminent risk of suicide – in other words, the client is highly likely to do something unsafe and is not manageable on an outpatient basis. All of these risk and protective factors are important, but certain factors point to imminent risk: intent and means, severity of psychiatric illness, the presence of psychosis or hopelessness, and lack of social support and other resources (Hirschfeld, 2001). Here is the SPRC’s list of risk and protective factors related to suicide, which can guide you as you assess and manage risk in clients. 

Risk factors are characteristics that makes a person more likely to consider, attempt, or follow through with suicide. Major risk factors for suicide include:

  • Prior suicide attempt(s)
  • Misuse and abuse of alcohol or other drugs
  • Mental disorders, particularly depression and other mood disorders
  • Access to lethal means
  • Knowing someone who died by suicide, particularly a family member
  • Social isolation
  • Chronic disease and disability
  • Lack of access to behavioral health care
  • Recent loss including job loss, relationship breakup, gambling loss, etc.

 
Conversely, protective factors are personal or environmental characteristics that help protect people from suicide. Major protective factors for suicide include:

  • Effective behavioral health care
  • Connectedness to individuals, family, community, and social institutions
  • Life skills (including problem solving and coping skills, and the ability to adapt to change)
  • Self-esteem and a sense of purpose or meaning in life
  • Cultural, religious, or personal beliefs that discourage suicide
  • Willingness to reach out for help and support from others

 
Know what to do: create a safety plan

If your client endorses risk for suicidality or homicidality, don’t panic. Staying calm can demonstrate that you’re both okay and can handle this situation together. Also, knowing your resources and helping the client create a safety plan is useful for those who are at high risk of harming themselves or others. The plan is typically brief, easy to follow, and in the client’s words. Clients can use the plan before or during a crisis. 
 
Safety planning is not to be confused with creating safety contracts or “no-harm contracts,” which was formerly common practice for suicide prevention. These contracts would involve written or verbal agreements that clients  would not harm themselves. A careful review of the literature by Kelly and Knudson at Idaho State University’s Institute of Rural Health in 2000 revealed that safety contracts were never shown in any studies to be an effective way to prevent suicide. 
 
In contrast, safety planning is a more comprehensive approach to suicide prevention and intervention because it focuses on what the person will do, rather than what the person will not do. Safety planning is a brief intervention consisting of problem-solving, coping skills, and crisis supports created collaboratively between client and clinician to reduce the risk of suicidal behaviors and increase treatment adherence. 
 
SPRC and the Department of Veterans Affairs have outlined the following components of a safety plan: 

  1. Recognizing warning signs that are indicative of an impending suicidal crisis (e.g. increased talking of death or wanting to die, seeing no reason to live). 
  2. Identifying and implementing coping strategies without needing to contact another person, such as reading an uplifting book, mindfulness exercises, or taking a walk. 
  3. Reducing the potential for use of lethal means, which might include removing access to pills, guns, knives, and other dangerous items from the client’s home. Some actions that could be taken are asking a family member to store or dispense medications safely, and locking up or giving firearms to a trusted person until the crisis has stabilized. 
  4. Utilizing contact with people as a means of distraction from suicidal thoughts and urges. 
  5. Contacting family members or friends who may help to resolve a crisis and with whom suicidality can be discussed.
  6. Contacting mental health professionals or agencies, such as a local crisis hotline or mobile crisis team. 
  7. If your client poses an imminent risk to self or others – in other words, if the client is unwilling or unable to commit to a safety plan and/or cannot be managed on an outpatient basis – do not leave them alone. Support them to go to the nearest emergency room for immediate assistance. This could involve encouraging them to call a family member or friend to accompany them, but be sure to assess whether they are willing to be safe on the way to the emergency room. If there are no other options, or they are unwilling to commit to any action to ensure their safety, calling 911 is the best course of action. Calling 911 or local law enforcement might prompt a welfare check, known as a wellness check, or active rescue in some states.  

Documenting the reasons for your actions and referrals is important. For instance, “The client endorsed active suicidality but denied intent to act on his thoughts,” or “The client agreed to a follow-up visit in one week and a safety plan, which includes….” Remember to continue monitoring the client’s level of risk and to revisit the safety plan if therapy with you is part of the treatment plan. 

It is also important to keep in mind the duty to warn, also known as the Tarasoff rule, which refers to the responsibility of a mental health professional to warn and protect intended victims against danger when a client presents with the risk of serious danger or violence to another (American Psychological Association, 2018). After conducting a thorough assessment and determining that there is reason to believe that a client has communicated a current, serious threat of violence against an identifiable victim or victims, therapists are required to make reasonable efforts to communicate the threat to the victim(s), such as making a phone call, and to notify the local law enforcement.

These guidelines can be used when conducting a risk assessment over video, but there are some additional steps you can take to prepare for a video session, such as confirming the client’s physical location, retrieving the client’s phone number and the phone number(s) for a close friend or family member that the client gives written permission to call in an emergency, and having the phone number of the police department handy. For more details on how to handle a risk assessment during a video session, you can view a sample video therapy protocol here

Your role matters

Mental health crises are common occurrences. Making sure you create a safe space for clients to talk about their painful experiences and harmful thoughts is the first step towards helping to restore their emotional health and sense of life purpose.  
 
Following the steps outlined here, competently and compassionately, can alleviate the emotional burden your client is facing and prepare them for a safer and brighter road ahead.  


INTERNET RESOURCES AND CALL CENTERS
American Association of Suicidology
American Foundation for Suicide Prevention
Suicide Prevention Call Center and National Suicide Prevention Lifeline: 1 (800) 273-TALK (8255)
Suicide Prevention Resource Center
 
REFERENCES
American Psychological Association (2018, January). What do we mean by duty to warn? Retrieved from https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2018/01/what-do-we-mean-by-duty-to-warn

Hirschfeld R.M. (2001). When to hospitalize patients at risk for suicide. Ann N Y Acad Sci
932:188-96; 196-199.

Stanley, B. & Brown, G. K. (2008). The Safety Plan Treatment Manual to Reduce
Suicide Risk: Veteran Version
. Washington, D.C.: United States Department of Veterans Affairs.

Stanley, B & Brown, G. K. (2012). Safety Planning Intervention: A Brief Intervention to
Mitigate Suicide Risk, Cognitive and Behavioral Practice, 19, 256-264.

Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients:
Scientific and clinical applications. American Psychological Association.

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DISCLAIMER: The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
 
ABOUT THE AUTHOR
Charlene Fuentes, Psy.D. is the Associate Director of Clinical Programs at Lyra Clinical Associates. Her clinical specialties include Cognitive-Behavioral Therapy (CBT), Health Psychology, and Behavioral Medicine. She has extensive experience in chronic illness management and has developed inpatient and outpatient psychosocial programs for hospitals in the San Francisco Bay Area.