Standardizing Risk Assessment Documentation

30 01 2007

There are no established formats for documenting a formulation of suicide risk. I have taken some steps to standardize this documentation in the clinical service I direct, but it needs further development. I’ll be helping our department arrive at a common format. Thankfully, I’ll be working with some really bright people who can view this documentation need from a variety of perspectives (compliance/QA, acute services, research). Here are some working principles:

1. Check boxes will not do. We can prompt clinicians with keywords, but like it or not, suicide risk formulation will always need narrative.

2. Our format needs to feel friendly and familiar to clinicians with a wide range of education and clinical experience.

3. The following elements should be present:

  • specific risk factors for suicide
  • non-specific risk factors for suicide
  • clinical data that mitigates risk
  • protective (or potentially protective) factors upon which to build treatment
  • summary clinical judgement about (a) chronic and (b) acute/imminent risk (there are some examples of metrics that define “low, medium, or high” or at least provide examples of each)

4. The format should eventually be standardized across our continuum of care.

5. Formulations with anything other than low risk, should somehow be addressed in treatment planning process.

6. We need to provide lots of documentation examples for clinicians to use as reference.

I’d be eager to hear from anyone who has a narrative format that satisfies some or all of these principles.


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Categories : documentation, evidence-based therapuetics, health care delivery, risk assessment

How we think about Primary Care “Gatekeepers”

27 01 2007

Primary care physicians are often grouped in as “gatekeepers,” who need to be able to ask about suicide, know warning signs, and refer. The tend not to get in-depth training about formulating or documenting risk assessments.

The problem with this “gatekeeper” view is that we don’t have the kind of seamless system that allows the primary care professional the luxury to leave the judgment call to a mental health professional. It’s not like they are standing at a gate, able to wave a patient on to a mental health professional on the other side. There are barriers to access, patients who refuse evaluations, and the need to make decisions about who warrants intrusive involvement and who does not. These are sophisticated clinical judgments that go beyond “know the warning signs.” PCPs have to be able to articulate an evidence-based rationale for allowing a patient to go home with an outpatient appointment versus involving a psychiatric emergency team.

I met with a group of pediatric primary care professionals this week. Our discussion brought this point home to me. They were eager to be trained in true risk formulation and documentation–and felt that these skills would help them feel less anxious about asking about suicide.

There may be some gatekeepers for whom instruction in questions, warning signs, and referral options is enough. But primary care gatekeepers need more.


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Categories : documentation, health care delivery, primary care, risk assessment, teaching/training

Risk and patient choice

25 01 2007

It’s hard enough to assess for suicidal risk, interview, reach a formulation, and develop a plan that matches the risk level. But what do you do when the client does not agree to the plan? It is difficult to manage one’s emotions, and difficult to know how to proceed. This is especially true when the recommended plan involves a higher level of care. Do you continue to work with the person in a setting that you have judged inadequate for the needs, or do you somehow insist or refuse to work with the person? How do you ddocument around these decisions?

Here are some initial thoughts I have about this unbelievably challenging clinical dilemma. I hope to articulate more principles and recommendations in future posts and papers, and would love to hear other clinicians’ ideas.

1. Articulate and document the rationale for recommendation AND for the treatment decision you make. For example: “I recommended partial hospitalization because the daily therapeutic contact, extensive group work, and focus on stabilization fit Mr. X’s needs in this case. I offered this recommendation to Mr. X and explained the potential benefits and risks of following this recommendation. I also explained the substantial risk I see in not pursuing this level of care at this time.”

2. Respect the client’s freedom, and avoid a power struggle. Most power struggles are born of anxiety. We sometimes do have totake coercive courses of action to protect a patient’s safety, but many times we twist patients’ arm to manage our anxiety more than their safety. This is not a black-and-white/either-or issue. We do need to honor our boundaries, our ethical/legal obligations, and have a level of comfort in order to work with someone. At the same time, clients with intact cognition (i.e, not psychotic or otherwise impaired from making rational decisions) and who are not at truly imminent risk need to have some latitude about the treatment they agree to participate in. Before drawing a line in the sand, we should be clear (and be able to articulate) why drawing that line is necessary for the patient and for the treatment.

3. If you decide to respect a client’s choice that goes counter to your recommendation (a la #2), document the clinical reasons why. If Mr. X refuses my recommendation to go to a higher level of care, I might write: “Mr. X refused the offer of partial hospital; he wishes to continue weekly therapy but agrees to nothing more. I agreed to continue to see him outpatient because (a) our alliance is strong and is a protective factor, (b) Mr. X has benefited from outpatient treatment, even though his acuity level makes him more appropriate for partial, (c) he is not in imminent danger, and (d) Mr. X’s cognition is grossly intact; his thought process is logical and coherent, and he is judged to have capacity to make decisions about the treatment he wishes.” I’m sure this is not a perfect note (and I’d be happy to hear from others about what you might write), but it captures some of the key elements that I think should be documented.


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Categories : documentation, patient choice, suicide, therapeutic alliance, treatment planning

Commitment to Living featured on PsychSplash

23 01 2007

Gareth Furber, who has a fantastic site called PsychSplash, featured CTL yesterday…a much appreciated mention that inspires me to keep the content coming! Here is the link to Gareth’s post.


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Categories : blogging

“How bad has it gotten?”

9 01 2007

When I teach about clinical interviewing, I often recommend this phrase (or some variation) as an entry point to questions about suicidal ideation. This accomplishes a couple of things:

1. Frames the discussion about suicidal ideation as one that is exploring the person’s subjective experience and suffering, avoiding the impression of ticking through the required elements of a clinical interview.

2. It begins a sequential approach where it then feels logical to ask about the extremes of desperation.

3. Signals to the person that you want to hear the full extent of the pain.

The exact words don’t matter, of course, but it is probably helpful for each clinician to develop a few standard ways he or she enters in to the conversation. This could be one of them.


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Categories : clinical interview, risk assessment, therapeutic alliance

Post from AAS/SPRC Workshop-Thoughts about staying therapeutic

4 01 2007

I’m in Ohio this week at a “train the trainer” workshop developed by the American Association for Suicidology (AAS) and the Suicide Prevention Resource Center (SPRC). The workshop is called “Assessing and Managing Suicide Risk: Core competencies for mental health professionals.” The training has been excellent so far.

The material focuses a lot on the therapeutic stance and alliance, including some excellent video of a master clinician interviewing a suicidal patient. It reminded me of something I’ve been emphasizing in the trainings I do: that a good therapist is a good therapist….the skill set is not radically different for the suicidal person. The problem is that many of us have been trained (by formal training or by our anxiety) to go into a some other mode when we encounter a person with suicidal ideation: we throw our best therapeutic skills out the window and become the suicide police. We often deprive people of our best skills because we feel we have to focus on nothing but their immediate safety. It is an unfortunate tendency because in the midst of deperation is when people most need compassion, empathy, and humanity–and a therapist who is as interested as they are in relieving the psychache.

So the challenge in developing and delivering training is to give equal weight to two important messages that are in some tension with one another:

“You must have a knowledge, training, and competencies specific to suicide. You must ask about it, document about it, and pay special attention to it.”

and

“Don’t get stuck on the suicidality or go into some different interpersonal mode. Compassionately tend to the person, the pain, and the problem, just as you always you.”

I think the training today did a good job of striking that balance. I hope my presentations and clinical work do too.


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Categories : psychotherapy, teaching/training, therapeutic alliance

At the crossroads of family therapy and suicide prevention

3 01 2007

I recently led a discussion about “Evidence-based risk assessment: implications for family therapy education, research, and practice?” at the Family Research Roundtable, which is a collaborative venture chaired by Susan McDaniel and Jane Tuttle, and funded by the University Committee on Interdisciplinary Studies.

My interest in the nexus between suicidology and family therapy is a natural one given the way my work has been evolving over the past year, but the intellectual spark for drawing the connection was a Grand rounds presentation by Paul Duberstein. In a brilliant talk titled, Standing at the crossroads of personology and prevention science: a view from suicide research, he made the following three statements that have stuck with me:

  • “Many people take their own lives because they did not receive adequate mental health treatment. Their traits, motives, and attitudes made it difficult for them to engage effectively with the mental health care delivery system and form a life-saving therapeutic alliance…It is this failure to seek and receive adequate treatment, perhaps more so than a mental or medical disorder, that is fatal.”
  • “We need to be creative and target at-risk patients, their family members, healthcare providers, and institutional settings. We need to enhance the ability to detect signs of distress, refer to treatment, and encourage treatment adherence and the development of the therapeutic alliance.”
  • “A truly person-centered health care delivery system is responsive to the “inseparable biopsychosocial entity” – and tailored to individual traits, preferences, attitudes, and communication styles.”

As a family therapist, my first thought was about the patients and family members we see who might not otherwise have contact with a mental health professional. Dr. Duberstein later made that same observation about family therapy in a subsequent talk I attended: During the presentation of a psychological autopsy he noted two points in the person’s life when marital and/or family therapy might have been helpful. These are potential “missed opportunities” we have to reach people who would not probably not otherwise seek treatment (i.e. they might come in because of marital problems or problems with their children, even when they might not seek help for themselves (or even conceptualize their problem as having to do with themselves).

There is lots of fodder for discussion here, but here are some possibilities occur to me. These are not formed conclusions, just ideas for exploration, comment, and study:

  1. Family therapists need to be strong in suicide assessment, including of family members who are not the identified patients.
  2. We need to figure out how to invite people in for treatment based on how they conceptualize their problems, and not force them to fit their problems into the way we organize our delivery system.
  3. (corollary to 2). We need to develop a flexible mental set about what kind of treatment we think is needed for people who contemplate suicide. A common assumption is that every person with significant risk for suicide or suicidal ideation needs to be first and foremost in individual treatment. If we think about suicide as failure in problem solving and an escape from pain, we have to ask…what problem and pain is the person motivated to address? Many people see their relationship difficulties as central and many (especially, perhaps, older men) will feel more comfortable learning problem-solving in the context of their family than in other forms of therapy we might offer.
  4. We need models for assessment and engagement with people who are not the identified (index) patient.
  5. No matter what the modality or paradigm, perhaps we need to think about who in a family needs help beyond the person who is the patient.

An additional empirical question that occurs to me is: how many people who died by suicide had a family member who was in treatment? We know that most people how die by suicide are never enrolled treatment, but I wonder how the numbers would look for family members.

Lots of thoughts, lots of questions swirling around as I stand at the crossroads of family therapy and suicide prevention.


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Categories : evidence-based therapuetics, family, health care delivery, suicide

Blogging about suicide risk assessment and prevention

2 01 2007

I have created an About this blog page to describe the purpose of this blog. I will be inviting colleagues to view this blog once the infrastructure is a little more mature.


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Categories : blogging