In college I volunteered for the National Suicide Prevention Lifeline, “a national network of local crisis centers” that provides phone counseling to those in distress.
The Lifeline did a fantastic job of training volunteers on Crisis Theory and Intervention-tools that I am sharing to help you assess for suicidality in your practice or agency.
If you are a practicing therapist, the first line of defense is to include a question about suicide in your intake assessment (i.e. “Have you now or in the past had thoughts of suicide?”) and explaining the limits of confidentiality in your Informed Consent.
To be less robotic about this it helps to say, “If this is something you are struggling with, the reason we break confidentiality is to get you the help you need. I will work with you on this and you will always be informed if I am going to break confidentiality”).
The four deciding factors of when to break confidentiality include desire, capability, intent and buffers.
“Desire” is the extent to which the person feels that they want to die (or “not be here” “go to sleep forever” “disappear” etc.)
This is generally emotionally charged; desire is about pain. (Note-not all folks deal with pain the same way, asking “how much pain are you in emotionally” does not equal “how much do you want to die.” Be direct).
“Capability” is how able a person is to take their life. This includes how easily they could access the means to die (weapon, medicines, etc.) If the answer is yes, get all the details you can, even though it feels voyeuristic. Ask what they’d use, where they’d be, what time of day, if they would be alone, etc.
“Intent” is how determined this person is to die. This includes a plan and intent to carry out the plan. Assessing this includes asking:
“Buffers” are the reason a person wants to live. Common buffers include social supports (family, friends, pets, etc.) life goals, core values, etc. Finding a client’s buffers helps to enhance their ambivalence about dying.
A sample statement for this is “even though you are thinking about dying, what things in your life might make you want to go on living?” Emphasizing a person’s ambivalence helps to remind them of reasons to live.
It’s important to assess for each of these factors individually, as none alone can indicate overall level of suicidality.
Taken together they can determine whether a person’s risk is mild, moderate or severe and help you decide when is a good time to break confidentiality to include mobile crisis, 911 or arrange with the client to have social support drive them to the hospital.
Always include a supervisor or other practitioner in your decision making; it’s best to make this decision through consultation.
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