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 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 had been holding the gun to his head, 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 long-standing 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 client’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.
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). The client 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 client’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 clients (Berman, Jobes, & Silverman, 2006).] He admits to current suicidal ideation and intent at this time. 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: SWUS1525
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