BOX 2: TAKING ACTION AND DOCUMENTING
Rate Risk (also use decision tree) Risk is: □ low □ low-moderate □ moderate □ moderate-severe □ severe □ extreme Take Action All the following actions can be taken by assessor: Low end of risk scale ○ Regular monitoring. ○ Provide patient with emergency numbers (1-800-273-TALK and local numbers).
○ Provide patient information about adjunctive treatment. ○ Encourage patient to seek support from friends and family. ○ Tell the patient: “If you begin to experience suicidal feelings and for any reason cannot get help, go to the closest emergency department or call 911.” ○ Document. Low to middle of risk scale (take previous actions and also) ○ Mid-week phone check-in scheduled for: ___________________. ○ Means safety/restriction interventions (ask about removing guns, pills, ropes from the home or restricting access in other ways). ○ Complete safety plan form with patient. ○ Complete a crisis card with patient. ○ Consult supervisor within 24 hours. Above middle of risk scale (take all previous actions and also): ○ Frequent phone check-ins. ○ Arrange for patient not to be alone (monitored by family member or friend). ○ Consult supervisor before patient leaves. Severe or extreme risk ○ Voluntary or involuntary hospitalization. Consult if: unsure of risk level or actions taken, moderate to severe risk level or above, notable increase in symptoms. Suggested documentation language : “Suicide risk was assessed according to Joiner et al. (1999) and determined to be [low/moderate/severe/extreme] due to … [e.g., ideation, plans, preparations, etc.]. Action taken: [e.g., safety plan, emergency numbers, consulted with supervisor, etc.]. Risk will continue to be monitored.” Note . Adapted from “Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update,” by C. Chu, K. M. Klein, J. M. Buchman-Schmitt, M. A. Horn, C. R. Hagan, and T. E. Joiner, 2015, Journal of Clinical Psychology , 71(12), pp. 1186-1200; and “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner, Jr., R. L. Walker, M. D. Rudd, and D. A. Jobes, 1999, Professional Psychology: Research and Practice, 30(5), pp. 1-7. Case study 5
Megan is a 37-year-old white female who presented for treatment of depression. She reported that she had been depressed her entire life. As a teenager, Megan abused alcohol and drugs, including amphetamines, marijuana, and LSD, and received inpatient substance use treatment at the age of 18. Shortly thereafter, Megan joined Alcoholics Anonymous and has not used alcohol or drugs since that time. Megan has attempted suicide twice, once by overdose and once by carbon monoxide poisoning, and cut herself in several locations while in substance use treatment. Megan was diagnosed with persistent depressive disorder and borderline personality disorder. She scored in the severe range on the Beck Depression Inventory (31) and reported frequent suicidal ideation but denied suicidal intent. Megan also reported difficulties in her romantic relationship and indicated that she had no close friends. In addition, she reported that she had been unable to maintain employment as a result of difficulty communicating with others. Discussion According to the Joiner model, Megan would be considered to be at severe risk because she is a multiple attempter and Determining the level of intervention Regardless of which framework approach is utilized, it is always necessary for an interviewing clinician to establish the suicide risk level of an individual AND select the appropriate level of intervention necessary to keep the high-risk individual safe.
has current suicidal ideation and at least two additional risk factors (depression, borderline personality disorder, relationship difficulties, thwarted belongingness, employment difficulties). In this case, the Joiner model would recommend taking the following actions: ● Consult with colleague or supervisor before patient leaves. ● Consider emergency mental health options with colleague/ supervisor (and offer to patient). ● Create a safety plan. ● Give emergency numbers including 1-800-273-TALK. ● Schedule mid-session phone check-ins. ● Attempt to limit access to lethal means (ask about guns, pills, etc.) and document if patient refuses. ● If patient leaves, arrange for patient to be accompanied/ monitored at all times until next appointment. ● If hospitalization is not warranted, get patient’s permission to elicit help/support from family members. ● For minor patients, notify parents/guardians. ● Continue to monitor risk in subsequent sessions. ● Document activities in progress notes.
While some completing this training may not have definitive clinical duties and responsibilities that require them to intervene with a patient, it is nonetheless important and potentially
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