Putting evidence Into Practice
The suicide risk assessment
Conducting a suicide risk assessment with a client who has problem gambling should cover the following areas:15,24,25
- predisposition to suicidal behavior (based on risk factors)
- stressors (e.g., significant financial loss)
- presentation of symptoms (e.g., symptoms of co-occurring mood disorder or personality disorder)
- presence of hopelessness and other warning signs
- access to lethal means, such as firearms
- previous suicidal behaviour (i.e., frequency and context, perceived lethality and outcome, opportunity for rescue and help seeking, preparatory behaviours)
- presence of protective factors (e.g., internal factors such as effective problem-solving and coping skills, and external factors such as strong family or community supports).
The discussion with your client will help you not only identify risk factors and warning signs but also their strengths and level of resiliency, which will help to encourage hope and reduce their risk of suicide.24 Keep in mind, however, that the presence of protective factors does not reduce suicide risk in clients with severe warning signs.24
One method that can help reduce your client’s anxiety about the risk assessment and help build your therapeutic relationship is to increase the intensity of the discussion using a gradual approach.25 Begin by identifying what brought on the suicidal thoughts, move on to questions about symptoms, then uncover the nature of their suicidal thinking.25
Use a clear and direct approach to questioning your client.26 As they provide answers, reflect on their answers to identify factors that might influence their risk level.8,14,18,27–31
Sample questions to identify factors that might influence a client’s risk level:8,14,18,27–31
- Does this client have a mental health diagnosis, specifically mood disorders and personality disorders?
- Does this client have a substance use problem?
- Is this client receiving gambling treatment?
- Does this client have an impulsivity problem or ADHD?
- Is there a family or relationship conflict?
- Did this client start gambling at an early age?
- Does this client steal to support their gambling?
- Is this client dealing with significant debt?
- Is the patient hopeless?
- Does the client have the capacity to act?
At the same time, the risk assessment only reflects your client’s suicide risk at a specific point in time.9 For this reason, it is a good idea to repeat the risk assessment at important life stages, such as following a change in clinical status or during a period of acute or extreme stress, such as after a significant loss.9,32–34
During the risk assessments, consider your client’s risk relative to a similar population, such as all clients who are receiving care for problem gambling (i.e., their risk status) and their risk compared to their own personal baseline or to other times in their life (i.e., their risk state).23,35
Intervention for high-risk clients
If the risk assessment leads you to determine that your client is at high risk of suicide, make sure that someone is with the client in a safe, secure room while you contact a psychiatrist with admitting privileges at a nearby hospital and/or arrange for an ambulance to bring the client to the hospital.36
If a client who is acutely suicidal refuses help, ask them about their access to lethal means (such as weapons or medications). Do what you can to make them inaccessible to the client.36 Call the police to help protect their safety.36
If the risk of suicide is high but not imminent, obtain your client’s permission to contact a family member or another person who is close to them. Inform this person of the problem and suggest they remain alert and available to help your client deal with the problem.36
Suggest to your client that they connect more frequently with you and let them know you’re there to help them stay safe.36
Discuss the various options available to reduce their suicide risk (see Table 5). Some of these options (such as pharmacological therapy) may require you to refer them to specialized services.36 Keep in mind that some clients are at higher risk of suicide in the days after they start psychiatric medications, so monitor them closely to identify potential problems as early as possible.36
Effective approaches to suicide risk reduction:
- Cognitive behaviour therapy (CBT)9,15,40,41
- Manual-assisted cognitive therapy40
- Dialectical behaviour therapy (clients with a diagnosis of borderline personality disorder)9,40,41
- Group therapy (with elements of CBT, DBT, and problem-solving therapy)15,40
- Family-based approaches40
- Active outreach (e.g., postcards, phone calls, and home visits)41
- Medications (e.g., antidepressants, anti-anxiety medications, lithium)9,40
- Electroconvulsive therapy (clients with treatment-resistant depression or intractable suicidal thoughts.)9,15
- Means restriction15,40
Once you have addressed your client’s immediate risk, focus on protective factors. For example, work with them to build their social support network and their coping and problem-solving skills.9,13,21,22
Developing the safety plan
After conducting the risk assessment, work with your client to develop a safety plan.32,37 This will help you gather information and identify resources your client can use in a crisis situation.34
Some areas to consider are listed below:34
- warning signs of an imminent crisis
- coping skills that help reduce distress in a crisis
- contact information for people who can help during a crisis
- contact information for mental health professionals or emergency resources (e.g., hotlines)
- potential lethal means the client should avoid
- ways to address practical concerns, such as people who can pay rent or feed pets if the client is in the hospital
- a list of crisis centres available 24 hours a day in Canada to keep within reach in case of emergency.
Once you have developed the safety plan, ask your client to consider whether the components are useful and realistic to them.34
Give the client multiple copies of the safety plan to keep in locations they can access easily in a crisis (e.g., wallet, nightstand and smartphone) and send to everyone who is listed in the plan.34 Revisit the safety plan with them at each visit to ensure it remains relevant and up to date.3
Dealing with a client emergency
Having a client who makes a suicide attempt or dies as a result of suicide can result in feelings of guilt, shame, disbelief, incompetence, anger, depression and fear for the clinician.38 In some cases, the clinician can exhibit symptoms that are similar to those of clients with post-traumatic stress.38
Proper training of clinicians who work with high-risk clients should include a comprehensive orientation on the topic as well as a mentorship model of training and supervision that includes role modeling of healthy responses to a client’s suicide attempt or death.38
Agencies with clients who may be at risk of suicide also should provide frequent opportunities for clinicians to discuss clients they consider to be at risk, so that team members can express their emotional responses to the work, learn from each other, and offer support.38
Approaches to coping with a client’s suicide that have been shown to be effective include talking with a colleague or colleagues who knew the client or who experienced a similar situation, performing a post-event case review, and seeking the support of a family member or other loved one.38
Clinical simulation video
Download video transcript
This video clip shows a fictitious therapist and client session for teaching purposes.
In this scenario, the clinician and client (Joseph) have worked together for many months and have developed a trusting therapeutic relationship. Since he presented as passively suicidal in the past, they have created a list of emergency contacts. In the video clip, the client presents with a flat affect and with thoughts of suicide. The clinician asks the client directly about the frequency of his suicidal thoughts and asks whether he has any plans for acting on them. The clinician then reviews options for further support and helps Joseph identify various coping strategies.
After providing the necessary referrals and supports, the clinician will continue to check in with the client regularly, closely monitor his mental status, document the plan thoroughly, and provide an update to the inter-professional team (including the psychiatrist) about the client’s current risk level and plan.