Let’s Talk About Risk Assessments

CW: This post discusses suicide in general terms.

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I wrote this piece to help therapists do a better job with risk assessment and talking to clients about suicide. Recently, I have seen evidence that many mental health professionals are not as comfortable talking about suicide with clients as we need to be. Of course, this statement does not apply to every therapist out there, and if this isn’t you, then great! Please also know this is a very brief overview of the topic and not meant to substitute ongoing education.

In my graduate training, I remember risk assessment being focused less on client need and more on clinician liability. Absolutely, as a therapist I need to think about my liability! If I lose my license, I can’t help any of my clients (or pay my student loans). But if I am not putting my client’s needs first, I am not doing my job. So what does that mean regarding talking to clients about suicide?

Quick disclaimer before I continue: I am speaking here to my own clinical judgement and style. Although we all need to be comfortable talking about suicide with clients, and we all need training in risk assessments, the specifics of how I handle this are unique to my practice, and each clinician has to decide what is best for their practice.

When do I ask clients about suicide?

I have a standard set of safety questions that I ask at intake. When working with young kids, I ask parents about safety concerns separately from the child, since sometimes children feel uncomfortable giving me an honest answer. I make a point of asking about self-harm behavior separately from suicide, since these are not the same thing.

If a client reports passive suicidal ideation (thoughts of suicide without plan, means, or intent to act on those thoughts), I regularly check back in about this. If a client denies suicidal ideation, I screen less frequently, since it can damage rapport to keep asking if the client said they are not suicidal. If at any time a client’s symptoms increase or they say something that makes me think they might be having suicidal thoughts, I ask again.

We know that asking about suicide does not cause someone to have suicidal thoughts, but as a new therapist, it was difficult for me to get this irrational belief out of my head. But it is absolutely essential that we address our own anxieties, get past them, and ask.

How do I ask about suicide?

I work with a pretty broad developmental range in my practice, so this varies. I always ask parents about “safety concerns” and whether their child has “tried to hurt themselves on purpose” at all ages. I also ask if the child has made statements about “wanting to die” regardless of age. However, I am not about to sit down with a three year old and ask if they have suicidal thoughts. I spent a lot of money and time learning about clinical judgment, so I use that in each situation.

One choice I often make around the language I use is that, depending on the client, I do not always use the word “suicide.” This is because I have had experiences with middle and high schoolers who will say that no, they do not have thoughts of suicide, but when asked if they think about dying or ending their life, they say yes. (My theory is that it is like how some people will say no, they have not been assaulted but will go on to describe things that absolutely meet the definition of assault – they just don’t relate to the technical term.) As soon as a client uses the term “suicide,” I mirror their language preference, but this is something that has made a lot of clients more comfortable talking about these thoughts. Again, this is not necessarily the right choice for every clinician, just something I have found helpful.

When do I recommend hospitalization?

I have seen some unsettling comments that clinicians have been taught to hospitalize any client who expresses suicidal thoughts. This goes back to the liability concerns I mentioned at the beginning of this post. This policy is going to absolutely cause harm to clients and is why we need better training in risk assessment.

The fact is, many people who have suicidal thoughts are not going to act on them. Of course, we have to continue to monitor passive thoughts and prioritize client safety, but this means that someone saying that they have suicidal thoughts does not automatically mean they need to be hospitalized. Hospitalization is an important resource for someone who cannot safely be out of the hospital, but if it is not the needed resource, it can do more harm than good. In fact, many suicide behaviors occur immediately after a hospitalization.

So if a client shares that they are having suicidal thoughts but do not intend to act on them, I ask questions about plan, means, and intent, and I encourage them to talk to me about the thoughts. What triggers them? What specifically do the thoughts look like? How does the client feel about having these thoughts?

Many clients have these thoughts but are not appropriate for hospitalization, and having the opportunity to talk about these thoughts in an outpatient setting can be highly beneficial. Now, if they share that they have a plan and means to act on that plan, we discuss hospitalization. Or if they share that they do not necessarily want to form a plan to end their life but are engaging in high-risk behavior, I might suggest hospitalization to keep them safe.

Risk assessment is a terrifying part of our job as therapists! We want our clients to be safe, and losing a client to suicide is horrifying. But when we lead with that fear, we end up putting our anxiety ahead of what is best for the client.

Therapist Aid has a free suicide risk assessment that can guide you when talking to clients about suicide, and PESI offers continuing education about risk assessment. I encourage any mental health professionals reading this to take steps to be competent in risk assessment so that we can do the best we can for our clients based on their needs.

Published by Dr Marschall

Dr. Amy Marschall received her Psy.D. from the University of Hartford in September 2015. Her clinical interests are varied and include child and adolescent therapy, TF-CBT, rural psychology, telemental health, sexual and domestic violence, psychological assessment, and mental illness prevention. Dr. Marschall presently works in the Child and Adolescent Therapy Clinic at Sioux Falls Psychological Services in Sioux Falls, South Dakota, where she provides individual and family therapy and psychological assessment to children, adolescents, and college students. She also facilitates an art therapy group for adolescents and college students with anxiety and depression. Dr. Amy Marschall is certified in Trauma-Focused Cognitive Behavioral Therapy and Telemental Health.

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