Managing suicide risk in therapy: a framework for deciding how to respond

Recently I had an interesting conversation with one of the psychologists I supervise. It highlighted something many of us get wrong about managing clients at risk of suicide.

The case

She has been seeing a client for a long time. He has long-term, low-level suicidal ideation. He has a plan, and the plan is lethal. He has always been able to commit to his safety and say he won’t act on it.

Then something changed between sessions. He lost his job and had a significant conflict with his partner.

My supervisee is understandably worried. His risk is higher, and she wants to do something: call the police, send him to hospital, act to manage the acute risk.

But the question isn’t what the level of risk is. The question is what responses are available, and which one is justified.

Two spectrums that don’t line up

Risk is a spectrum with a thousand gradations. At one end is the lowest level of risk. Nobody is at zero, including you, reading this. All our clients carry some risk of suicide, and monitoring it is part of the job. At the other end are people who are acutely unwell and intend to act immediately.

Our response is also a spectrum, but it has only a handful of steps.

• Watchful waiting. We observe, monitor and look at what we can do in therapy.
• The middle options. Referral back to the GP for a medication review, referral to a psychiatrist, engaging the person’s social network, treating the underlying mental illness.
• Breaching confidentiality to inform a significant other, to help keep the person safe.
• A police welfare check, where police knock on the door to see if the person is okay.
• Hospitalisation, to manage acute risk during an acute crisis.

Every step up has a cost

Each step up the response ladder carries its own risks. Breaching confidentiality, for example, can damage the therapeutic relationship and make it more likely the client will discontinue treatment.

So we use an elevated response when the benefit of reducing harm outweighs the risk the response itself carries.

The question to ask

When risk rises, the instinct is to ask, “How do I escalate my response?”

That’s the wrong question. The right one is this: has the level of risk escalated to the point where the next level of response is justified, given the risks it carries against the benefits it will bring?

Risk can move by a thousand small degrees. Our responses can’t. Our job is to manage that short ladder of responses as well as we can against the long spectrum of risk.

For clinicians who want to go deeper on assessment itself, Associate Professor Jacinta Hawgood’s Fundamentals of Suicide Assessment is available through PREP.

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If you’re reading this and struggling yourself, please reach out. Call Lifeline on 13 11 14, or 000 in an emergency.