Suicidality and Safety Plans

One area of critical importance in working with clients who struggle with depression, anxiety, and OCD is ensuring that a thorough assessment of suicide risk and a plan in coping with suicidal ideation is completed during the assessment and throughout treatment.  Even if a client does not have a history of suicidality, a safety plan is a good thing to discuss and have in place.

Safety Plans should include the following:

• Activites that clients have engaged in that have helped them avoid suicide and parasuicidal behaviors in the past or if there is no history, activities they imagine would help them cope. This may include activities they have learned to use on their own and skills they’ve learned from other therapists or peers. As therapy moves forward, this component should be enhanced as a client’s skill set expands.
• List of informal supports (family members, friends, sponsors) a client can reach out to if they are feeling suicidal – these can include support groups that hold frequent meetings (AA, NA) or online communities a client feels comfortable with as long as these online resources do not glorify suicidality or self-harm. Informal supports (depending on the level of risk) should be informed by the client as to their presence on the plan and what they can do to help in the event the plan is needed.
• List of formal supports clients can reach out to (this should not only include the client’s therapist, but the client’s general practitioner and psychiatrist).
• The phone number to the National Suicide Hotline, the hospital the client would prefer to receive a screening from in the event it becomes necessary and emergency services should also be on this plan.  Clinicians should talk to clients about what to expect when they go to the hospital and clients should feel confident that the clinician will speak to hospital staff and advocate on the client’s behalf in the event a hospital-based assessment is needed.
• Part of the plan may also mean, depending on the client’s history and current presentation, making their living situations safer.  We should ask about guns (especially with male clients), medication stockpiles etc and then recommend (often temporary) changes to the environment to keep the client safe. In some cases, treatment may be contingent on these changes occurring.

I continue finding myself feeling surprised by the number of clients who have experienced suicidal ideation and have engaged in suicidal/para-suicidal behaviors who have never been coached on risk levels, their meaning or the appropriate actions to take at each level. Generally, clients believe they will be forced to go to the hospital if they disclose suicidal ideation to a healthcare professional. This may lead clients to believe they need to evaluate symptoms by themselves for fear that telling a healthcare professional (or anyone else) will automatically lead to hospitalization.  This is not too far from the truth as inexperienced clinicians who are not properly supervised may be overly conservative or reactive in their response to a client disclosure of suicidality.  In other cases, schools as an example, a referral to screening is the immediate response to disclosure as per policy.

It’s important for therapists to take the time to be thorough and upfront with clients about the actions they would usually take depending on the level of risk they feel a client presents with. In many cases, clients and I have been able to develop in-home protocols that have helped them avoid hospitalization while still ensuring safety. In other cases, it meant a referral to a higher level of care that allowed the client to receive more intensive treatment and still go to work and remain home. Sometimes it meant the client and I agreeing that receiving screening at a hospital was the best course of action for the client.  The fact that a plan with multiple options was developed prior to the need to discuss hospital services almost always helped clients feel more confident that when a recommendation for screening was made, it was because it was in their best interest and not a reactive response to disclosure. It also made them far more comfortable with the referral.

There is a lot more to this than just the initial assessment and plan. A thorough assessment and comprehensive initial plan can help clients feel more comfortable in disclosing suicidal thoughts to their therapist. It can also help clients feel more equipped and comfortable with next steps when these thoughts occur.