TREATMENT INTERVENTIONS

and RISK MANAGEMENT of Suicidal Clients

EPC 695B: Advanced Behavior Disorders

Treatment Interventions: Extreme and Severe Risk

  • Notify significant other (spouse, parents, friends)
  • Remove means, if at all possible and safe for therapist and client
  • Client should be monitored at all times
  • Hospitalization
  • Psychiatric evaluation for possible antidepressants or other necessary meds
  • Regular contact with prescribing physician
  • If hospitalization is impossible – client does not qualify for commitment under state law and refuses voluntary commitment

a. Increase sessions, if possible

b. Frequent telephone contacts

c. Frequent suicide assessment

d. Maximum involvement of significant others where non-toxic

e. Keep client informed about all you are doing

f. Possible non-suicide pact (written is preferable)

  • Clinician should consult
  • Maintain accurate records

Treatment Interventions: Mild to Moderate Risk

  • Increase frequency and duration of outpatient sessions & check insurance

a. Help client develop strategies for self control, problem solving,

seeking social support.

b. Focus on reducing impact of identified stressors

c. Consult with psychiatrist

  • 24 hour availability or adequate alternative coverage

a. Clients familiar with coverage arrangement

b. Coverage providers fully briefed

  • Medication: Regular contact with prescribing physician
  • Consider day treatment or activities that decrease the client’s isolation
  • Focus on safety in treatment: removal of lethal agents (e.g., guns, pills, etc.)
  • Be alert to sudden changes in behavior
  • Consistent involvement of family/significant others who have agreed to help protect client
  • Keep client (and other involved individuals) informed about your plans and implementation of plans.
  • Put emergency procedures on card and give card to client and all family members who have agreed to help protect.

Treatment Interventions: General

  • Risk Reduction: Primary Focus

Focus on most significant risk factors, such as:

Decrease in frequency, intensity, duration and specificity of suicidal

behaviors

Decrease in suicidal behaviors

Help client develop alternatives to suicide

  • Risk Reduction: Secondary Focus

Work on reducing symptomatic variables, such as:

Hopelessness

Depression

Severe Anxiety

Impulsivity

Anger management

Work on individual characteristics that increase risk, such as:

Attributional Style

Cognitive rigidity

Problem solving ability

Taking responsibility for own actions

Need long term treatment for success

  • Safety Contracts

Commonly used technique, but reliance on these agreements is rarely

a good preventative clinical practice.

Many believe that it has clinical value but only if there is a strong and

long-standing alliance.

If used, therapist must assure client that s/he is available toclient if

and when client tries to reach the him/her (i.e., the therapist is

available 24 hours) or client should be aware of availability limitations and length of time it is likely to take to reach provider

during off hours.

Safety contracts are not recommended when client is a substance abuser

or has serious impulse control problems

Safety contracts are almost never valuable as a risk management technique; use of safety contracts without using other interventions

probably increases practitioner disciplinary risk.

Risk Management with Suicidal Clients

  • Clinical records are a must, because:

a. May discourage plaintiff attorneys from going forward

b. Can reduce settlement amounts

c. Bad records lead to liability and high settlements

d. Particularly important to document reasons why client was not hospitalized

e. Never alter a record – no single act so destroys a clinician’s

credibility in court

f. Know what state laws require to be included in records

  • Consultations must be carefully recorded

a. With colleagues (or supervisor) from the time you recognize

your client is a suicide risk

b. When suicide risk reaches severe level, discuss your client with

a professional with seniority/expertise

c. Consultation with all other involved professionals on regular

basis, e.g., prescribing physician

d. Consultations with client’s family

e. Consultations with managed care case managers, particularly

requests for hospitalization and additional services

Special Consideration in Treating Chronically Suicidal Clients

  • These clients are extraordinarily difficult to treat

a. The possibility of suicide is often an important part of a defensive

structure as the only means of escaping from intractable psychic

pain.

b. Gestures often are means of secondary gain acting out of rage.

  • Always continue regular consultation
  • Be certain you have the emotional resources – these situations create high stress and require enormous investment
  • Avoid treatment where you question your expertise.
  • Be alter to counter-transference issues

a. Narcissistic feelings of personal responsibility

b. Rage

c. Burnout

  • Be aware of the conflict between ability to provide good treatment and the duty not to abandon the client.
  • Abandonment: A mental health provider has a right to withdraw from a case,

but if s/he discontinues services before the need for them is at an end,

s/he must first give due notice to the clientand afford the client ample opportunity to secure other treatmentof his/her own choice

  • Avoiding abandonment complaint

a. Appropriate termination is key

b. Consultation is necessary - with colleagues or supervisor, and/or managed care case manager to develop alternative resources,

and/or with prescribing physician

c. Termination during hospitalization may be appropriate.

d. Consult with hospital staff.

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