Conducting a Safety Assessment
Few things are more nerve racking than conducting a safety assessment when a client is threatening to kill themselves or harm another. It takes courage for the therapist to ask direct questions about the client’s thoughts or actions intending to hurt himself or someone else. This type of courage is a required skill if you are to work successfully in this field.
Can a therapist prevent someone from hurting himself or another? No.
What then, is the responsibility of the therapist? To conduct a clinically competent safety assessment and, based on that assessment, act in a way showing a standard of care similarly trained persons would do, in a similar situation, given the information received.
The therapist is not ultimately responsible for the safety of another. However, she is responsible to ask the direct questions and formulate, then deliver, an appropriate set of interventions.
A therapist is required to break confidentiality if a person is determined to be a threat to another, identified victim. This is a legal requirement on the part of the therapist, who is required to inform both the police and the intended victim.
If the person is a danger to himself the therapist does not bear a legal requirement to break confidentiality, but therapists are generally permitted, if the situation requires, to break confidentiality in order to maintain client safety.
Not all individuals who think of hurting themselves require involuntary hospitalization. A sound safety assessment will look at:
- The level of risk from low to highSee SAD PERSONS scale. But remember the SAD PERSONS scale is not diagonstic!
- An assessment of the client's social supports
- Possible removal of weapons
- Increased level of contact with the therapist
- A formal safety assessment (see the questions below)
The therapist should formulate interventions following the idea of least restrictive measures
. The therapist should seek to maintain a persons safety that is least restrictive of the client's civil rights.
A progression of restrictive measures may look like: verbal no-harm contract, written no-harm contract, voluntary hospital admission, involuntary hospital admission.
A No Harm Contract is not a contract nor a legal document, but an agreement, that cannot promise a persons safety. These agreements outline what a person needs to do if he or she becomes suicidal. They are best thought of as diagnostic and help form your assessment of a persons ability to maintain their own safety.
Click No Harm Contract and download an example of a No Harm Contract developed by Murray State University, College of Education.
If a health and safety check is to be conducted either the police or, if available in your county, a psychiatric emergency team can provide the needed assessment and invoke a 5150.
Documentation of the clinical course of action is extremely important in all cases where safety is of concern. The purpose of documentation is to protect the therapist indicating the results of the safety assessment and the actions taken to competently and appropriately address the client’s safety. Documentation helps the clinician's self supervision in not overlooking important clinical standards.
While there are many types of clinical charting, in many crisis/safety situations narrative charting is preferred.
Narrative charting is time based where the clinical actions and/or information received are noted in chronological order and the information is written in paragraph form.
In California a 5150 is commonly called a “Hold”. It refers to the CA Welfare and Institutions Code 5150 which applies for the involuntary holding of an individual for 72 hours for evaluation and treatment if the person is found to be a danger to themselves, a danger to another or gravely disabled, due to a mental disorder. Gravely disabled generally means the person is unable to provide for their own food, clothing or shelter.
In California a hold can be “broken” before 72 hours by a designated licensed mental health care professionals at a treating facility. This usually means a psychiatrist.
If a person is deemed to remain “hold-able”, or a continued danger to themselves, another or gravely disabled due to a mental disorder, they may then be placed on a 5250 which extends the “Hold” for 14 days.
A “14 Day Hold” can be extended to a temporary conservatorship, then a full conservatorship in which another person or county agency is designated to take legal and financial control of the patient’s affairs. 5250’s, and both stages in the conservator process require hearings in front of a judge or administrative officer to help ensure a patient’s rights are being protected and all those interested are acting in the best interest of the patient.
It can not be stressed enough that if you are concerned for a client’s safety, or the safety of another, always get clinical consultation or supervision.
Safety Assessment Questions
Danger to Self
1. Have you had any thoughts or actions, now or in the past, to do anything to hurt yourself?
2. Are you concerned about your ability to maintain your own safety?
3. Is anyone else concerned about your ability to maintain your safety?
4. What, exactly, are any thoughts you have had or are having to hurt yourself?
5. Do you have a plan on what you would actually do to hurt yourself?
6. Have you ever acted on these thoughts? What did you do?
7. Regarding any past actions to hurt yourself, was your intention to…hurt yourself, die, let someone know how bad things are?
8. What were you trying to get away from or are you trying to get away from, by doing something to hurt yourself?
9. How are you hoping hurting yourself/killing yourself will solve your problems?
10. Do you have the means to hurt yourself? Do you have access to weapons or drugs?
11. Has anyone in your family ever hurt themselves/committed suicide?
12. What level of support do you have in your life?
13. Are you willing to make a no-harm contract with me?
Click Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) to receive a FREE digital copy of suicide assessment guidelines put out by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Danger to Others
1. Have you had any thoughts or actions, now or in the past, to do anything to hurt someone else?
2. Have you ever acted on these thoughts? What did you do?
3. Regarding any past actions to hurt someone else, was your intention to…(a) get them to stop doing something, (b) make them start doing something, (c) intimidate them, (d)let them know how bad you feel?
4. You mentioned being angry with ___________. Is this the person you are thinking about hurting?
5. What, exactly, are any thoughts you have had or are having to hurt ____________?
6. Do you have a plan on what you would actually do to hurt him/her?
7. Do you have the means to hurt others or the intended victim? Do you have access to weapons?
8. Are you concerned about your ability to control your impulses and not hurt someone else or _____________?
9. Is anyone else concerned about your ability to control your actions?
10. How are you hoping hurting others or ____________ will solve your problems?
11. Is there any history of violence within your family?
12. What level of support do you have in your life?
13. When you have acted out with anger in the past have you been under the influence of alcohol or drugs?
14. Are you willing to make a no-harm contract with me?
Learn the useful skills I have found over twenty years of experience that will help you provide great service to your clients. Click on my text Secrets of a Psychotherapist.