“Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning.”

“Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical.”

“When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress.”

My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn’t address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.

This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.

Fowler, J. C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90. doi:10.1037/a0026148

How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Mental health care was not organized to fit the way many people at risk utilize services. Much of outpatient mental health is organized around a fantasy that most patients will (1) Make an appointment ahead of time for an evaluation; (2) come to that appointment at the specified time; (3) make another appointment; (4) come to that appointment; (5) work on a signed treatment plan in between.

Now, that model probably does work well for some people. But for many individuals at risk, that level of organization and consistency is not congruent with their lives. If it were, they wouldn’t need us! The situations that make professionals the most nervous are the ones where the patient (1) Makes an appointment.  (2) Comes to the appointment later in the day or the next day crying and upset, hoping to be seen. (2) Misses the next appointment.  (3) Makes it to one appointment with the psychiatrist. (4) Misses 2 of the next 3 appointments with the primary therapist (5) can’t recall the treatment plan when asked about it. Naturally, clinicians get frustrated and wish the person would either sign-up or drop out.

But of course it’s not the fault of the individual at risk that we’re set up the way we are, or that all the empirically supported treatments assume the patient is actually in treatment. I’ve addressed this issue here, here, and here when I’ve talked about how to manage patients who violate the “social contract” of being a patient. But there’s something distinctly anxiety-provoking about someone who is loosely connected to mental health services, compared with someone who actively refuses plans we suggest.  It can be especially hard if the loosely-connected person only shows up when in crisis.

This won’t be a surprise to those who have followed my posts, but my approach to the loosely connected person hinges on two core clinical tasks: connection, compassion, and documentation.

Connection means that we should have the bias of keeping people involved to the level they are able.  I know that this is difficult in the context of productivity demands and limited resources.  You can’t have 80 people on your caseload who all miss 75% of appointments.  But I think we should condition ourselves (and set up services) to have a least a few people like that because the resources might be well spent in being a bridge to life for the person.

Compassion is always core. It can be hard to feel and show compassion to someone in crisis when they haven’t taken the least first step to try ideas you’ve given. It’s easy to find yourself thinking, “Maybe if you came a little more often, you wouldn’t be in this position.” It’s especially hard to find compassion for someone who is at-risk for suicide and not showing up because it feels like they could take us down with them. All of those thoughts are natural, and it shouldn’t end there. Instead, we have to summon the courage to enter in to the suffering one more time, offering the main thing we can offer under these circumstances: a caring commitment to living.

Documentation is one way I get to that place. One barriers to compassion is fear.  It takes courage to keep working with someone who has only one foot in the room–especially when they present with suicide risk. Part of every clinician’s brain is occupied with worry under these circumstances–worry about losing a patient, worry about being blamed, worry about being sued. It’s hard to have compassion for someone if you think they could ruin your life. Having an unassailable risk assessment and other supporting documentation can put the fearful part of the clinicians brain to rest and make way for the kind of compassionate connection the hurting patient really needs. In other words, one of the key purposes of documentation is to quiet fears that might interfere with caring–and with doing the right thing. Once you’re confident about documentation, you can focus on doing what’s best for the patient, instead of feeling cornered into defensive courses of action.

Connection, compassion, and documentation share at least one thing in common: they are easier said than done. Their importance is so obvious that it may be tempting for an experienced clinician to speed passed these concepts. Anyone NOT think connection, compassion and documentation are important? Of course not. But, as with most simple good ideas, there are complex barriers to implementing them. Each person has to identify his or her own barriers and find a way to build these principles in to every day practice.

If you’re going to be in Orlando on April 24, please come by and say hello.

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Although I have a section called “protective factors” in the map I use to teach about risk formulation and documentation, I am increasingly finding myself replacing these words in workshops with the awkward phrase, “Launching off point factors.”  What I mean to convey is that it is probably best to think of “protective factors” as factors that increase the likelihood of success for crisis and treatment planning, rather than factors that technically “protect” against risk previously identified.  A distraught, intoxicated individual with suicidal ideation and a gun can have all the protective factors in the world and that doesn’t change the risk one bit.   These factors may, however, present opportunities to engage in crisis planning, develop a therapeutic relationship, and engage a supportive system, all of which create conditions in which risk can be addressed, and which could ultimately influence decisions about the most appropriate level of care.

In our next revision of risk-related documentation, I’m considering recommending that we get rid of the term “protective factors” altogether because of the danger that it can be misleading.  I don’t have a great substitute, unfortunately.  Best I can come up with right now is “Opportunities for Crisis and Treatment Planning,” but I wonder if an ordinary person coming to a section so-labelled would know what it meant.  Needs more work.

The Urge To End It, by Scott Anderson, is a stunning piece.  Well-written, and well-researched, it challenges the stereotype that suicide is always well thought out, carefully planned, and the result of a conscious and un-ambivalent decision.   He focuses on the impulsivity and momentary desperation involved in many suicide attempts, and raises awareness about means restriction as a potent intervention.

For clinicians, there are several important take-home points and cautions:

• Expressed suicidal ideation is only one part of an assessment of risk for suicide;  impulsivity, high intensity stressors, and agitated emotional pain signal as much about risk as suicidal ideation.
• We need to ask about available means and seek to disable lethal means whenever possible.
• We need to advocate for public policy that promotes means restriction–this may save the life of someone in our care (or in our lives).
• Ambivelance runs deep.   Even in the moment of jumping, survivors report feeling regret, not wanting to die.  We are built for living, and those who help distressed individuals have a powerful force on our side.
• We need to ask about how bad the pain is and how intense the desire for escape, even (especially) with individuals who have not previously expressed suicidal ideation.

There are probably other lessons from Anderson’s excellent article, including understanding more about the subjective experience of someone who attempts suicide.   The article is not short, but you’ll be rewarded for the time spent to read it all the way through.

One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment.  Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment?  How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I’m looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

• the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.
• the writer is correctly concerned about putting all eggs in the self-report basket.   A person at risk who is not stable may not be able to follow through with intentions to get help.   It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context
• the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.

This is such a good question that I wish I had put it on my docket of questions to blog about.  And it relates as a follow-up question to one that is on that docket, “When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient’s agreement to voluntary actions:

• Document assessment of reliability of self-report.  When assessing and documenting self-report the following should be considered and noted:
  • past experience, if any with the patient as a reliable reporter or not.   “Pt. has reliably followed through on medical decisions and plans in the past.”
  • evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question.   If not, “Pt’s thinking is logical, coherent, and reasonable.  Judgment is intact.   No indication of impaired capacity to make decisions and follow through with them.”
  • degree of patient cooperation.  Explicitly note that the person volunteered information, though s/he didn’t have to.   “The patient has been open, cooperative, and collaborative in the assessment and planning process.  There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”
  • impulsivity.   The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself.  If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that.  “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances…”
• Show your reasoning.  The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors.  This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”
• Say what you didn’t do.  Related to the previous point, it as as important to document the road NOT taken.   This shows that you took the situation seriously and considered the full range of options.
  • A corollary to this principle is to note risks associated with alternative courses of action.   “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization.   The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”
• Document consultation.   Much more consultation occurs in primary care than is ever documented.   This would be a time to do it.  One line is sufficient:  “Discussed case with Dr. X who concurred with the plan.”

Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I’d be interested in feedback and ideas from who employs these principles in their documentation.  I would also be interested in reading comments with other ideas about how to address the situation the questioner described.

Note that the post has ads embedded in it. Besides being annoying, the ads throw off some of the formatting, so you have to scroll down to read the text.

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