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by: Magdalena Werne, AMFT
Gray Area of Suicide Means Individual Planning The topic of suicide may feel tough for trainees and associates to navigate through with clients. Suicide in the state of California is a gray area, meaning if a client is experiencing suicidal ideations, a mental health clinician is not mandated to report and– break confidentiality to report the client’s suicidal state. Each case that presents suicidal symptoms is different; therefore, providing individual-based care is essential when providing suicidal safety planning for clients.
Suicide Screening Ensuring client care involving suicidal ideation and behavior must include assessing for suicidal ideations and behaviors. Suicidal screening is paramount when assessing suicidal presentation. Legally, a clinician does not need to be correct in suicide assessment; however, under the duty of care, a clinician must provide suicide assessment when observing a client's suicidal ideations and planning behaviors (Griffin, 2022).
Suicide Assessments Assessment may be explored and measured differently based on the individual needs of the client and may include various suicidal screening measures, such as holding a basic curiosity about a client’s past and current display of suicidal thoughts, behaviors, and planning during the intake session. Ongoing inquiry and assessment may be necessary depending on the severity and overall display of suicidal thoughts and behaviors. Prominent suicide measures a client may take individually include the Beck Hopelessness Scale and the Reasons for Living Inventory. In contrast, suicide measures administered by the clinician to the client may include assessments such as the popular SAD PERSONS, Suicide Intent Scale, and Columbia-Suicide Severity Rating Scale C-SSRS (Griffin, 2022; Klott, 2012).
Importance of Gathering Records and Information Providing the standard of care if a client exhibits suicidal thinking and behaviors may include obtaining past records comprising of the client's psychiatric hospitalizations, noting previous suicide attempts, and psychiatric evaluations, and speaking and corresponding with the client’s prior and current suicide care providers (Griffin, 2022; Mason et al., 2022).
Documenting (and documenting some more!) is necessary after providing suicide assessments and receiving and reviewing client records. Remember, if you do not document, it never happens. Remember also to document the client’s response to treatment during sessions, partaking in suicide assessment, and engagement with your prevention care.
Remember, if you do not document, it never happens.
While administering suicidal safety care with a client, continually ask yourself if the dimensions of care you are providing are reasonable standards of care, including safety planning, obtainment of documents concerning the client’s suicidal history, suicide assessments, consultation, and implementation of safety steps.
Red Flags Circumstances to note when helping clients with suicidal safety comprise recognizing that older men living alone, individuals experiencing feelings of self-disgust, and being disconnected from others are more likely to die by suicide. Other factors relating to higher suicide attempts or death by suicide include separation from partner, depressive symptoms, and disordered eating (Corrigan & Schutte, 2023; Mason et al., 2022; Olfson et al., 2022).
Providing Reasonable Care for Clients Displaying Suicide Under your duty of care, if a client displays suicidal ideation, behaviors, and planning, administrating reasonable safety and prevention steps is the standard of care for clinicians. Reasonable steps must be developed based on the needs of the individual. Examples of reasonable steps may include increasing the number of weekly sessions, reaching out to check on the client, making medication referrals, referring for a psychiatric evaluation, and collaborating on a suicide safety plan and protocol for the client to follow if experiencing the threat to harm oneself.
Seeking out a higher standard of care, such as an intensive outpatient program, may be necessary if the client is presenting severe and immediate emergency suicidal thoughts, behaviors, and planning (Griffin, 2022).
Be Prepared to Ensure you know your county’s psychiatric emergency or mobile response teams' contact information. Also, make sure the client’s emergency contact is current. Hospitalization and calling 911 for a client’s suicide emergency may also be necessary. Please be aware that increased suicidality is common for individuals post-hospitalization after suicidal care; therefore, knowing the risks will help guide the clinician on what imperative steps to take, such as participating in a collaborative-based care model and seeking ongoing consultation while documenting. As a pre-licensed clinician, when treating suicidal ideation and behaviors, consultation with your supervisor and collaborative care are necessary. When treating clients presenting suicidal thoughts and behaviors, working with assistance is imperative. Additionally, maintaining referrals if the client needs a higher standard of care, such as intensive outpatient care, will help contribute to your client's support.
Suicide and Confidentiality As a clinician, you are protected by California law to break confidentiality if doing so is in the best interest of treating and protecting the client from foreseeable self-harm. Be sure to clearly document your break of confidentiality and list the reasons you are assessing the foreseeable threat of self-harm (Griffin, 2022).
California Civil Code-Breaking Confidentiality in Cases of Suicide Prevention Section 56.10(c)(1) of the Civil Code states, “The information may be disclosed to providers of health care, health care service plans, contractors, or other health care professionals or facilities for purposes of diagnosis or treatment of the patient…” (Griffin, 2022). This means that the therapist would be permitted to communicate with the client’s physician or another mental health care professional, to name just a few examples, without a release if such communication was for the purpose of diagnosing or treating the client.
Section 56.10(c)(19) of the Civil Code states that a psychotherapist can disclose confidential information about the client “if the psychotherapist, in good faith, believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat” (Griffin, 2022). Document all steps taken to prevent suicide, including the client’s response to treatment.
Needed Consultation and Documentation Consultation is as important as documenting your clinical treatment. As a pre-licensed clinician, you can rely on your licensed supervisor to help guide you when a client presents suicidal ideation and behaviors. Documentation of ongoing consultations is of the utmost importance when assisting a client with suicidal features. Ensure all assessments, observations, reactions of the client, and consultations are documented.
Important Reminder Using language such as “committing suicide” implies that the individual committed a crime. In California, suicide is not illegal; therefore, legally, no crime is committed. Instead, using better language, such as “died by suicide,” is more appropriate.
Suicide Resources 988 Suicide/Crisis Number Call or Chat with 988 for suicidal emergency/crisis Open 24/7 Call 988
Chat 988: Suicide Prevention Help with Didi Hirsch
Legal or Ethical Questions Concerning Clients Exhibiting Suicidal Ideation, Behaviors, and/or Planning?… Call the CAMFT Legal Team for Consultations
Article Resources
Corrigan, J.A., Schutte, N.S. The Relationships between the Hope Dimensions of Agency Thinking and Pathways Thinking With Depression and Anxiety: a Meta-Analysis. Int J Appl Posit Psychol 8, 211–255 (2023).
Griffin, M. (2022, March). Attorney articles: Working with suicidal clients. CAMFT. Klott, J. (2012). Suicide and psychological pain: prevention that works. Premier Pub. And Media.
Mason, D., James, D., Andrew, L., & E. Fox, J. R. (2022). ‘The last thing you feel is the self-disgust’. The role of self-directed disgust in men who have attempted suicide: A grounded theory study. Psychology and Psychotherapy: Theory, Research and Practice, 95(2), 575-599.
Olfson M, Cosgrove CM, Altekruse SF, Wall MM, Blanco C. Living Alone and Suicide Risk in the United States, 2008‒2019. Am J Public Health. 2022 Dec;112(12):1774-1782. 10.2105/AJPH.2022.307080
Magdalena Werne, AMFT, provides therapy services to clients in a private practice setting under supervision of a licensed professional. She specializes in working with adults who have survived childhood maltreatment and traumas. She is passionate about Brainspotting and Internal Family Systems and hopes to one day open her own private practice. Magdalena has recently begun Internal Family Systems Level Two Training, and Positive Psychology is a developing interest. Magdalena became a mental health clinician to help individuals and family systems increase healthier connections to the self and the other. She enjoys swimming, mountain trails, gardening, and spending time with her dog, Leo.
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