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 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
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). 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. 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).]
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Book Code: SWUS1524B
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