lifesaving to follow the same procedures outlined with regard to assigning risk level and appropriate level of intervention. Depending on the specific situation, determinations need to be made about the patient’s ability to manage the situation. For example, it is often necessary for the therapist to take control when suicidality is related to certain risk factors such as high-risk psychiatric disorders (e.g., schizophrenia), prominent feelings of pain and a wish to escape, or risk that is acute. When the specific situation is related to a patient’s personality disorder that presents with chronic suicidality and prominent feelings of anger, Jacobs and colleagues (1999) recommended giving the patient more control and responsibility in managing the situation. Although patients with personality disorders may exhibit a clear predominating set of features, it also should be remembered that they can shift toward greater risk and always need to be fully evaluated. In such cases, the clinician should be ready to take more responsibility than was previously appropriate. If suicide risk is deemed high in these patients, the clinician needs to ensure that the individual is in an appropriately safe and secure environment. It is vital that the clinician organize reassessment Documentation The final part of assessment is always documentation. If a responsible clinician fails to document, then for all legal intents and purposes, the assessment never happened. Likewise, post-hoc documentation cannot be completed after an adverse event has already occurred (e.g., after a suicide attempt); it is essential that a risk assessment be completed and finalized as soon as possible after the assessment has occurred. Box 2 of the Joiner assessment approach provided some potential language Case study 6: Clinical example of documentation The following is a fictional documentation summary of a difficult suicide risk assessment case. Richard Moore is a 48-year-old white man who was seen for an assessment of suicidal danger. The patient was referred by his individual psychotherapist, Liz McGinley, LCSW, who is employed at the local community mental health center. Ms. McGinley’s working diagnoses for this patient have been major depression, recurrent, without psychotic features; alcohol abuse; personality disorder, NOS (not otherwise specified). The patient has had about 1 month of sobriety according to his therapist and also started on an antidepressant medication approximately 1 month ago. When asked why he was referred to this emergency assessment, he replied, “Well I have been having some suicidal thoughts.” Upon further questioning, he said, “Last night, I got out my gun, loaded it, and put it to my head a few times. I really wanted to pull the trigger, but, Doc, I just did not have the courage to do it. And, you know, I don’t think I will do anything like that again.” Of special interest, Mr. Moore indicates that at one point when he was holding the gun to his head the previous evening, he went outside and fired the pistol into the ground. It was a way of “practicing, I guess,” he said about this preparation behavior. In terms of precipitating events, Mr. Moore indicated that 3 days ago his wife left him. He explained that there had been longstanding tension in the marriage due to his alcohol abuse. The marital distress continued after he stopped drinking alcohol. With respect to prior attempts and suicidal behavior over the last 2 months, Mr. Moore stated that he threatened to kill himself about 3 weeks ago when his wife expressed her wish to leave him. He described getting the same handgun and holding it to his head, as he had done last night. Mrs. Moore agreed to return to Mr. Moore, and that ended the patient’s crisis at that time. Mr. Moore reported that he had attempted suicide twice; both times were by drug overdose about 4 and 5 years ago. He was having marital problems at that time also.
within 24 hours. The clinician should make sure that contingency plans are in place for rapid reassessment if distress or symptoms escalate. Clinicians need to assess a patient’s competence to enter into a treatment process when suicidal danger is acute. The patient should be able to explain the risks and benefits for each treatment course considered. Given the extreme constriction that often is evident with suicidal patients, seeing alternatives may be quite a challenge for them. For example, patients experiencing a recent relationship breakup may be experiencing high levels of stress and suicidal ideation and may believe that the only solution left is suicide. They may have convinced themselves that they are unlovable and will never find love again because their partner has left them. If a patient’s competence to consent to treatment is impaired or if the clinician judges that the patient is at imminent risk for suicide, involuntary treatment (usually hospitalization) should be sought. More details on specific suicide interventions will be covered in subsequent sections of the course. that can be used in documenting suicide risk assessment and intervention strategies. However, any documentation language used should meet the requirements of the setting and agency in which the at-risk individual is assessed, and as long as the note covers the key aspects of risk and intervention, there is room for individual clinicians to elaborate on points that they think are most relevant. The following case study highlights specific issues to consider with documentation. The patient does not have much of a support system at this time. He has an adult daughter, but she lives in another state and is not available to him; she tends to side with the mother in the couple’s disputes. He reports having no friends. A mental status examination was completed. The patient’s mood and affect are both depressed and anxious and have grown much worse the last 3 days. He is not sleeping well (has got about 3 hours of sleep per night over the last week) and has a greatly diminished appetite. He is oriented to person, place, and time and evidences no memory problems. He has a recent history of alcohol abuse; he and his therapist believe this problem is now in remission. His similarities and proverb interpretations were concrete, suggesting some thought constriction. He reports feeling hopeless. [Note: A mental status exam has obvious clinical value but is also a risk management tool when evaluating suicidal patients (Asghar-Ali & Boyle, 2018).] He admits to current suicidal ideation and intent at this time. However, he says he could not commit to his safety and rated the strength of his intention to kill himself an 8 on a scale of 0 to 10. Mr. Moore appears to be at high risk for suicide given his current crisis, lack of support, and history of multiple attempts. He seems to have recently moved down the pathway to preparation for suicide. He has access to lethal means. Mr. Moore indicates that he does not want to be hospitalized due to his fear of the consequences of absence from work. Although inpatient hospitalization would disrupt his work schedule, his danger to self outweighs this concern. The next lower level of care, partial hospitalization, would have the advantage of allowing him to stay at home in the evening, but would still disrupt his work schedule and would also appear to be inadequate in providing the protection he needs at this time. Continuing outpatient therapy, or even increasing his outpatient contact to daily, might help circumvent his work concerns. This, too, would obviously be less than the structured intervention he now seems to require.
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Book Code: PYCA1423
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