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On the last track, we discussed teaching self-appraisal to clinical supervisees. We also discussed the six point supervisee self-assessment that I use regarding working and evaluating skills. The five points in this assessment are action steps, focusing, reframing, confronting, and pointing out endings.
On this track, we will discuss training supervisees in ten steps that can help a therapist cope with a client who might be at risk for suicide.
In the intake process, you clearly screen out from referring to the inexperienced supervisee clients who are at risk for suicide. However, issues may arise that were not apparent during the initial intake of the client that later create a risk for suicide. Coping with the risk that clients may commit suicide creates a special set of responsibility for the supervisor to convey to the supervisee. Because of the consequences, I strongly advise you provide suicide risk initially via a discussion and perhaps following it up by playing this track.
10 Step Screening for Suicidal Risk
The following 10 steps may be helpful in coping with the chance that one of your supervisee’s clients might be at risk for suicide.
Step #1 - Assessing Suicide Risk The first step, clearly, is assessing a client’s suicide risk. I remind my supervisees that in addition to risk taking, withdrawal, giving away possessions, and other well-known suicide warnings, some clients who have decided to end their own lives may suddenly present as very calm and happy after a long period of sadness and depression. Have you reviewed the key warning signs of suicide with your supervisees? Does your organization have a suicide risk evaluation procedure that your supervisee should become familiar with?
Step #2 - Is there a Specific Plan A second step involves assessing whether the client has a specific plan to carry through. In short, the supervisee needs to ask him or herself, "what is the difference between my client merely considering suicide, and actually taking action?" Therapists generally agree that professionals have a duty to interfere with client’s efforts to end their lives.
Perhaps you have heard of cases where the therapist is sued by a significant other of the client who has committed suicide or attempted to commit suicide. Thus, documentation of assessment for suicide risk when deemed appropriate is crucial. Have you informed your supervisee of your agency’s policies and procedures for non-voluntary inpatient admission?
Step #3 - Arranging an Safe Environment A third step in coping with a client’s potential suicide risk is to work with the client to arrange an environment that will not offer easy access to instruments the client might use to commit suicide. If a client has purchased a specific weapon or tool, this may involve encouraging the client to place the weapon in a place to which they have no access. Does your supervisee need to work with a psychiatrist or physician regarding prescribing psychiatric medication to the client, as well as to ensure the client does not have enough medication with which to overdose.
Step #4 - Creating a Supportive Environment In addition to screening for suicide risk and helping to arrange a safe environment, a fourth step is to work with the client to create a supportive environment. Clearly, family and friends can be the best resource, but I also encourage my supervisees to become familiar with what community services can offer, as family support may not exist, or be detrimental, for some clients. What community services information has your supervisee been provided with?
Step #5 - Justifying Realistic Hope A fifth step in coping with the potential risk regarding suicide is to justify realistic hope. I feel that is it important for my supervisees to learn to recognize and work with a client’s strengths in order to discuss practical approaches to the client’s problems. This positive focus increases the therapist’s chance of communicating realistic hope and working with the client’s temporarily minimized desire to live. I of course feel that it is vital to point out to my supervisees that they should not deny or minimize the client’s desire to die.
Step #6 - Using Contracts I have found, like you, that a sixth step in coping with a client’s potential risk of suicide is the use of contracts. I explain to the supervisee that these contracts form an agreement between the client and therapist in which the client agrees not to attempt suicide in a given time frame, sometimes as short as the interval between sessions, or agrees to contact the therapist before a suicide attempt. Would you agree that even if the client only grudgingly accepts the contract, the contract may give the client a psychological reason to resist an otherwise overwhelming suicide impulse?
Step #7 - Exploring Fantasies Regarding Death In addition to screening for suicidal risk, arranging a safe and supportive environment, justifying realistic hope, and using contracts, a seventh step in coping with a client’s potential risk of suicide is explore fantasies a client may have regarding death. I explain to my supervisees that reevaluating unrealistic beliefs about what death will and will not accomplish can be an important step for clients attempting to remain alive.
Step #8 - Ensuring Clear Communication and Evaluating Potential Impact An eighth step for coping with potentially suicidal clients that I teach to my supervisees is to ensure clear communication and evaluate the potential impact of any interventions. I explain to my supervisees that ambiguous or confusing messages may cause considerable harm. An inexperienced therapist spent much time in the session convincing her suicidal client how much her children needed her.
Thus the mother became convinced that her children needed her, but went a step further, telling herself that her children could not live without her. At the same time, the mother considered herself totally worthless. What do you suppose was the unintended result of the misconstrued message from the therapist? The mother then decided to kill not only herself, but her children as well, to spare them growing up without a mother, and followed through with her plan.
Step #9 - Being Sensitive to Negative Reactions to Client's Behavior A ninth step for coping with potentially suicidal clients is being sensitive to negative reactions to the client’s behavior. I explain to my supervisees that it is normal for therapists treating suicidal clients to become fatigued and frustrated, and that is important to be aware of signs of potential negative countertransference. You might convey to your supervisee that a therapist absent-mindedly glancing at his or her watch through feelings of fatigue or frustration can be highly damaging to a suicidal client.
Step #10 - Expressing Caring In addition to screening for suicidal risk, arranging a safe and supportive environment, justifying realistic hope, using contracts, exploring fantasies of suicide, ensuring clear communicating, and being sensitive to negative reactions, a tenth step in coping with a client’s suicide risk is expressing caring. I explain to my supervisees that the most important way to communicate this caring is by being willing to listen and take seriously what the client has to say.
I feel that for many clients experiencing a risk of suicidal behavior, one of the most important issues is for the client’s message to get across. The client’s individual needs and beliefs, and those of the therapist, influence what precise channels for communicating caring are healthy and appropriate. I encourage my supervisees to continually reassess what method will best communicate to a suicidal client the message that "I hear you, I recognize that this is a tough decision. I will be glad to listen, and if I can’t help, we’ll find someone who can."
Would playing this track for your supervisees be beneficial in helping them develop a framework for coping with potentially suicidal clients?
On this track, we have discussed discuss training supervisees in ten steps that can help a therapist cope with a client who might be at risk for suicide. These ten steps are screen for suicidal risk, assess if the client has a plan, arrange a safe environment, justify realistic hope, use contracts, explore fantasies of suicide, ensure clear communication, be sensitive to negative reactions, and express caring.
On the next track, we will discuss sexual attraction to clients, and determining appropriate levels of nonsexual physical contact with clients.
Clinical Supervision and Professional Development
of the Substance Abuse Counselor
- Center for Substance Abuse Treatment. Clinical Supervision and Professional Development of the Substance Abuse Counselor. Treatment Improvement Protocol (TIP) Series 52. HHS Publication No. (SMA) 144435. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.
What are ten steps a supervisee can use in coping with a client’s risk of suicide?
To select and enter your answer go to Answer Booklet.