The Practitioner Conection
Volume XXV, 1st Quarter

INTERVENTION AND DOCUMENTATION FOR THE SUICIDAL PARTICIPANT

Although we cannot always prevent suicide, we can make attempts to decrease the risk by identifying the risk factors through a comprehensive suicide assessment and a psychiatric evaluation followed by attending to the participant’s safety and establishing a plan of action and a treatment plan. During the assessment and at follow up it is important to engage the participant. Building a strong therapeutic relationship is an important first step. A participant must feel a sense of trust in an atmosphere that is conducive to openness with thoughts and feelings. At the same time, the treating provider must be as upfront as possible about treatment options -- except in emergent situations, where full disclosure might be hindered by the need to assure the participant’s safety.

After doing a suicide assessment and evaluation and, once the participant’s safety is assured, a decision must be made on the treatment setting. If the participant’s condition warrants inpatient treatment, more decisions must be made about the level of observation necessary to keep the participant safe. The participant may require suicidal precautions, such as one to one visual contact with staff. In more extreme cases with someone who is acutely suicidal or self-abusive, physical and chemical restraints may be required.

Once the treatment setting is established, the rest of the treatment planning can begin. The treatment plan should include a crisis plan for those who are not admitted to an inpatient unit. This crisis plan should give clear directions about when and how to seek additional help or support and when to call or when to go to the emergency room. A crisis plan should be written out for the participant and those involved in the participant’s care and safety.

As part of the assessment and treatment plan, the practitioner should always try to encourage the participant to allow family, friends or significant others to be part of the participant's treatment, crisis and safety plan. Having additional support can, in itself, be a protective factor. Supports such as family can also significantly contribute to the participant’s adherence to the treatment plan, participant monitoring and contacting practitioners should the participant's situation change. Attempts to secure or eliminate any potentially lethal devices, such as additional medications in the home or firearms, should also be made. Having supports can be helpful in establishing that these potential lethal means have been secured or removed

Barriers to treatment adherence must also be discussed and planned for. Barriers may include prior negative experience with the mental health system, social stigmas, transportation problems, financial difficulties, limited supports and potential medication side effects, to name a few. Participants and supports should be educated on the treatments available including treatment settings, somatic and psychotherapy treatments. They should be aware of what to expect from treatments, including time frames for medications to work, the types of practitioners who will be involved in care, and the role each will play. Participants should be monitored closely in all settings when a potential risk for suicide exists, even if they are in an inpatient setting.

The stabilization of suicide risk factors like depressive symptoms, anxiety, insomnia, irritability, command hallucinations to harm self, etc., as well as treatable psychosocial stressors should begin soon after the assessment is completed. The choice of psychotherapy or somatic treatments or combinations of both will depend on factors such as the severity of symptoms and the diagnosis. Although some medications, such as antidepressants, do not work right away, there are other faster-acting medications which can target symptoms such as insomnia or anxiety. Even certain symptoms like a sense that one will not get better can be addressed at the initial assessment and on an ongoing bases to instill hope for the future and thereby decrease the risk of suicide. Treatments including psychotherapy can be very helpful even after a single session and should be initiated as soon as possible. One should try to alleviate any psychosocial stressors, such as finding placement for someone who is homeless or seeing if a family member or friend can stay with the participant if they live alone. Therefore, it is crucial to begin treatment to address all symptoms and psychosocial issues as quickly as possible.

Documenting the assessment, evaluation and action plan is critical for medical and legal purposes, for other practitioners who may be involved in treating the participant, for cross-coverage purposes, to provide a complete history if a consultation is needed and for overall good clinical care. It is important to be able to look back at previous notes to see what actually occurred, as we cannot always remember all the details with accuracy. The full psychiatric evaluation and suicide assessment should be documented. This should include a well-documented treatment plan, a listing of who was contacted and what support people were present. A crisis plan and treatments discussed should be documented as well as plans for addressing various symptoms. One should clearly document reported or not reported suicidal thinking, intent or plans as well as potential means and possible access to potentially harmful items such as firearms, and how these issues will be addressed. It is also wise to document when the potential means, such as a firearm, are secured or removed.

For more details about APA practice guidelines regarding suicidal behaviors and assessment and treatment use this link: http://www.psych.org/psych_pract/treatg/pg/SuicidalBehavior_05-15-06.pdf

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