Best Practices by Natalie Jambazian, AMFT

Suicide Risk Assessment: Best Practices Prevention

Making critical decisions and assessing risk factors is one of the most challenging jobs of a mental health professional. I remember my first client in private practice, frantically nervous in my waiting room and in crisis mode. I knew I had to assess for a plan, means, intent. I knew all of that but at that moment it felt real and I wanted to make sure my client did not leave before I could give her all the resources available to me. When I called my supervisor, I felt calm, and I knew I had great support from one who could give me the best direction to ensure I offered the proper standard of care. I now understand why we have to collect 3,000 hours in order to become licensed. Experience and patience can make you a great therapist, in addition to learning through your instincts. By understanding what is going on inside your client's mind, recognizing the warning signs, and having an assessment sheet and resources, can help tremendously. Research has shown therapists underestimate clients' suicidality and sometimes fail to catch the warning signs.

The law says we must take "reasonable and appropriate steps" to prevent suicide, which sounds vague since it depends on the client's risk factors. However, there is a standard of care we have to follow as clinicians. Also, there is no way of completely knowing and being certain, since clients may minimize their ideation.

What can you do to follow the standard of care and take reasonable steps to prevent harm?

• Obtain an informed consent from the client
• Discover a client's past history of attempts
• Obtain written releases to talk to anyone with helpful information about the client's history or current state (i.e., Psychiatrist, medical doctor)
• Evaluate the client's level of hope, symptoms of depression, finalization of personal affairs, and ability to carry out suicide
• Consult with other professionals
• Understand the knowledge of risk factors
• Increase contact with the client
• Use interventions that are appropriate to the level of crisis (I would first lean towards voluntary, and if then necessary, involuntary hospitalization)
• Refer for psychiatric evaluation
• Conduct a treatment plan — includes involving a family member
• Create a no-self harm agreement
• Look into psychotic disorders that may be a cause
• Always document, document, document!

What are the Warning Signs?

• Extreme self-hatred: "I don't deserve to live."
• Hopelessness: "Nothing matters anymore," "What's the point?"
• Pushing away friends and family: "What's wrong with me? Look at all this trouble I'm causing the people who love me."
• Isolation: "I am better off alone."
• Thoughts of not belonging: "I don't fit in anywhere."
• Symptoms of Depression: irritability, sudden mood change, change in appetite and sleep.
• Increased substance use.

Minors and suicide:

It is a best practice to let parents/guardians know the suicide risks, unless you find it is harmful to do so.

The following are some questions you can ask yourself to cover the grounds:

1. Was the therapist aware of the risk factors?
2. Was the therapist systematic in assessment of the client's suicide risk?
3. Were there "reasonable and appropriate steps" taken to gather information?
4. Was the assessment data misused, leading to a misdiagnosis, perhaps?
5. Was the therapist responsive to the client's crisis?
6. Did the therapist look at all interventions necessary to protect the client?
7. Did the therapist make attempts to keep the client safe (i.e., set up a plan with resources, emergency contacts, social support)?
8. Did the therapist remove the means to be used by the client in the suicide attempt?
9. In cases of minors, were parents or caretakers informed of the client's potential risk?

No therapist is able to predict with certainty what his or her client will do, nor can he or she control the actions of his or her client. The preventive measures, which a therapist employs when working with a particular client, depend on the needs of the client, the surrounding circumstances, and any information, which may be available to him or her regarding the client. For example, the therapist may wish to speak to the client's physician, family member, spouse, etc., because he or she believes that such communication will yield critical information, or, that it is necessary in order to prevent the client from harming him- or herself. In another example, a therapist may determine that calling the police is an urgent necessity in order to prevent the client (or some other person) from being seriously harmed. In such circumstances, a therapist is permitted to disclose confidential information about his or her client, subject to the provisions of Civil Code, Section 56.10(c)(1).

Note: It is always best practices to consult with CAMFT attorneys and document that you have done so:

http://www.camft.org
858.29.CAMFT
858.292.2638)

Natalie Jambazian is a Marriage and Family Therapist Registered AMFT working in private practice under the supervision of Anita Avedian, LMFT, CAMS IV. Natalie is currently an Anger Management facilitator through Anger Management Essentials and NAMA facilitating groups in Sherman oaks and Glendale. Anger Management 818 accepts both volunteer and court ordered clients, In addition, Natalie works with children, teens, and adults and her specialty includes but not limited to anger management, ADHD, PTSD, divorce, and grief. Natalie has received training in NLP, CBT, Mindfulness, and Trauma Focused Therapy. She is fluent in Armenian as her second dialect and can be reached at 818.334.8786 or via email at www.therapywithNatalie.org, Please visit her website at www.Angermanagement818.com.