Instead of no-harm or no-suicide contracts, I prefer working with clients to construct a uniquely relevant safety plan, a resource-based to-do list that identifies protective steps the client and his or her significant others are willing and able to undertake.
In developing the safety plan together, first decide how the client and significant others can restrict access to all possible means for attempting suicide. You can also explore reasonable alternatives to troubling behaviors for coping with distress and identify safe havens the client could access for a limited time if necessary. Write down the contact information for anyone who could offer a safe haven or other forms of support.
I once consulted on a case involving a young suicidal woman, Michelle, who had persistent thoughts of jumping off the balcony of her 11th-story apartment. Although her parents weren’t available to help, Michelle said she had a good friend, Vanessa, who lived on the ground floor of the same building. I arranged for Vanessa to come into our session, and the three of us worked out details of a safety plan. We decided that whenever the thoughts of jumping ramped up, Michelle would first go to her walk-in closet, which she considered a safe haven. Once there, she’d meditate and, if necessary, call the numbers of family, friends, and professional resources that we wrote down. If these measures didn’t feel safe enough, she’d take the elevator down to Vanessa’s, and—with the key that Vanessa said she’d give her once they got home—let herself in. Michelle didn’t consider or worry about any other methods of dying, so the measures necessary for keeping her relatively safe were fairly straightforward.
A safety plan is designed as a temporary measure to get suicidal clients through distressing times, so you need to make sure the plan is reasonable and doable. A plan that’s too elaborate or demanding isn’t safe. In addition to significant others, you and the client should consider enlisting his or her work supervisors or school administrators to alter the client’s schedule, reduce his or her workload, or grant a leave of absence. Also, determine whether the client would consider initiating, resuming, or continuing relevant therapy or treatment. In addition to generating a list of personal and professional contacts the client could call if necessary, identify emergency contacts such as crisis lines and nearby hospitals. Once the safety plan is complete, make a copy for your file and give the original to the client.
If the client appears to be at imminent risk of making a suicide attempt and a safety plan doesn’t seem feasible or sufficient to keep him or her safe, then you’ll need to arrange transportation to a psychiatric receiving facility for evaluation and possible involuntary admission. But never make this choice simply to be on the safe side. Sending someone to the hospital who’s depressed but not suicidal, for example, may alleviate your immediate anxiety, but it may cause the client to avoid seeking out mental health treatment in the future.
Arrive at your safety decision by piecing together all the information you gather throughout the assessment: what the client tells you, what you empathically glean, and what you know from the professional literature about risks and resources. Whenever possible, consult with a colleague or supervisor, so you can compare your perspectives.
Once you make a decision, give yourself the opportunity to take a second look at it, along with the data informing it. If, upon considering everything a second time, you come to the same conclusion, then you can proceed with added confidence. If you end up with second thoughts, listen to your doubts and use them to prompt further information gathering.
It isn’t unusual for me during an assessment to change my mind several times about whether a safety plan can be a viable option for keeping a client alive. Much of what Michelle told me—about her depression, thoughts about jumping, absence of family—pointed to hospitalization as the best choice for keeping her safe. But glimmers of hope kept appearing, so I kept asking questions, and together we finally determined that she had the necessary resources to stay safe—and we were right. She told me much later, when the crisis had passed, that she’d pinned up her safety plan inside her walk-in closet and would go in there and read it as a source of reassurance and inspiration.
Ultimately, suicide assessments are inherently anxiety-provoking and emotionally taxing, even when they go well and the client can safely negotiate harrowing desires, thoughts, and circumstances. Following an assessment, it helps to secure time with colleagues to talk through how the client presented, what you were able to discover, what you decided, how the client responded to the process as a whole, and what you were experiencing throughout the process. Taking care of yourself in this way will help you feel better prepared the next time.
Douglas Flemons, PhD, is Professor of Family Therapy and Clinical Professor of Family Medicine at Nova Southeastern University. He’s coauthor of Relational Suicide Assessment, author of Of One Mind, and coeditor of Quickies: The Handbook of Brief Sex Therapy. He offers workshops on suicide assessment, hypnosis, and brief therapy. Contact: email@example.com.
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