DBT involves a pretreatment stage and four additional stages, each with its own intervention targets. The pre-treatment phase aims to forge a mutual commitment to eliminate suicidal behavior and entails an intensive approach with weekly individual therapy and skills- training groups. Stage one focuses on: (a) decreasing behaviors that are life-threatening, interfere with therapy, and diminish quality of life, and (b) increasing behavioral skills. Stage two addresses decreasing post- traumatic stress. Stage three aims at increasing respect for self
and achieving individual goals. Finally, stage four focuses on resolving a sense of incompleteness and finding freedom and joy. DBT skills are divided into several modules, including core mindfulness, emotion regulation, interpersonal effectiveness, distress tolerance, and walking the middle path. DBT therapists meet weekly with other DBT providers in consultative groups to help one another maintain a validating and “dialectic” stance toward their patients. The dialectic stance involves balancing validation strategies with change interventions.
CLINICAL DECISION-MAKING CONCERNS AND DOCUMENTATION
When mental health providers are dealing with individuals who are suicidal, it is imperative that they be aware of the legal implications related to the seriousness of suicidal thoughts. There are times when clients will need to be protected from themselves through hospitalization. At times, hospitalization Commitment criteria and imminent risk Experiencing elevated intent to act on a suicide plan is perhaps the primary cause for concern in suicide crisis evaluations of high-risk individuals (Jordan & Samuelson, 2016). An important clinician concern is deciding when to hospitalize a suicidal patient. This is especially the case when a patient reports elevated “intent” to act on suicidal thoughts or plans (Jordan et al., 2019). In this situation, the clinician has an ethical responsibility to ensure the patient’s safety (Obergi, 2017). Therefore, it is good practice to know and understand the applicable state statutes where one practices regarding options and obligations concerning involuntary treatment. Most states offer an option of pursuing involuntary commitment if a patient is endangering him- or herself or a third party as a result of psychiatric illness. See the Resources section for a link where practitioners may access their state’s statutes. Once clinicians have a good working knowledge of the state laws that govern involuntary commitment, they still are faced Standards of care Clinicians need to be thorough in their assessment of each client on a case-by-case basis. It is only after a careful and comprehensive assessment that a clinician is able to determine each client’s risk factor. Although it is possible that different risk elements can be considered in arriving at a legal standard of care for suicidal clients, the clinician needs to be guided, first and foremost, by clinical standards – i.e., What is in the best interest of this client given his or her needs and the available alternatives? (Obegi, 2017). Clinicians always are responsible for doing what is reasonably possible to enhance client safety and care (Chu et al., 2015), and the areas of client self-harm and suicidality are especially important for clinicians to address through risk assessment and risk management (Crowe, 2018). When documentation is guided by clinical standards and a clinician “thinks out loud” in terms of considering the pros and cons of each of the disposition alternatives, sound risk management is achieved for the clinician should a client attempt or complete suicide. Crowe (2018) advises: Documentation of suicide risk should state more than, “Patient denied suicidal ideation at this time.” It is also important to document the safety plan that is created with the patient and/or in consultation with colleagues/ Clinical example of documentation The following is a fictional documentation summary of a suicide danger assessment. Richard Moore is a 48-year-old Caucasian man who was seen for an assessment of suicidal danger. The client 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 client have been major depression, recurrent, without psychotic features; alcohol abuse; personality disorder, NOS (not otherwise specified). The client has had about 1 month of sobriety according
even may be involuntary. It is critical that clinicians be aware of the need for professional documentation of their decision- making process when dealing with clients who are at risk for suicide. The following section reviews various issues related to commitment and documentation issues. with the difficult decision of when to recommend this step for patients who are seriously at risk for engaging in self-harm. Unfortunately, there is no concrete, universally accepted definition of “imminent risk” for suicide. Suicide risk likely varies from minute to minute, hour to hour, day to day (Kleiman et al., 2017). This makes any prediction about imminent suicide, in Simon’s words, “illusory.” Moreover, time attenuates the accuracy of suicide assessments that are “here-and-now” judgments. Therefore, according to Simon, suicide assessment must be a process, not an event (Sommers-Flanagan & Shaw, 2017). Outpatient settings are not an appropriate level of care for patients who express a clear imminent intent and acknowledge possession of means to kill themselves. If such patients are unwilling to voluntarily admit themselves to an inpatient setting, they do meet the criteria for commitment to a secure inpatient hospital setting. supervisors in addition to the typical information included in the patient documentation form. Increased face-to-face and phone contact is recommended during times that the patient is experiencing, or signaling, suicidal ideation in order to continue to assess whether the patient needs additional care at a hospital. Following up with the patient is crucial in the prevention process. Suicide is the most common cause of legal action against mental health care professionals (Jacobson, 2017). Documentation is the cornerstone of the defense of a potential suicide case. Good care combined with good documentation is the surest way to avoid being sued for malpractice. From the perspective of attorneys who review suicide-related matters for prospective plaintiffs on a weekly basis, the quality of documentation can determine whether a malpractice attorney accepts or declines a suicide case (Stanley et al., 2019). When assessing suicidal clients, consulting with knowledgeable colleagues not only helps the client, but also adds to the clinician’s risk management strategy. Documenting that this consultation occurred, as well as the issues considered, is a wise risk-management strategy (Obegi, 2017). 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 last night when he
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