Addressing Imminent Risk | Considering Hospitalization
In my three-part blog series on Suicide Assessment, I introduced a framework to guide assessment based on the Four Core Principles used by 988 centers nationwide. I then explored how to gather the information needed for a full assessment, focusing on how to ASK about suicide, LISTEN to your client’s story, and CLARIFY missing pieces of your assessment. The final part of the series focused on using the gathered information to formulate the degree of risk and PLAN with clients for safety. While a client at acute high risk - or what is often termed imminent risk - is largely a low-frequency occurrence, it is important to know how you will respond should you need to consider hospitalization in order to keep your client safe.
Imminent Risk
Determining that your client is at risk for suicide does not always mean hospitalization. There will be times when, despite active suicidal thoughts, your client has no expressed intent to act on these thoughts and is capable of developing a safety plan, removing access to means, engaging supports, and/or increasing the frequency of sessions. That is, hospitalization is not needed and the brief interventions previously reviewed – developing a safety plan and addressing access to lethal means – as well as ongoing suicide-focused therapy can support your client through the current suicide crisis.
But what happens when this is not the case - when brief interventions are insufficient to maintain safety?
Maybe you have begun to develop a safety plan only to realize that your client will not realistically be able to follow through on the safety measures discussed or they are unable or unwilling to address access to lethal means. What action do you take then?
In the most recent post discussing risk formulation, this was identified as Acute High Risk where, following your full assessment, you have determined that you need to consider hospitalization to maintain your client’s safety.
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A client at acute high risk - or what is often termed imminent risk - is largely a low-frequency occurrence. This client would likely express thoughts of suicide (DESIRE), have a plan, and engage in preparatory behaviors (INTENT). Their CAPABILITY to act may be enhanced by a history of suicide attempts but they would also have access to lethal means.and have a difficult time developing a meaningful safety plan.
Clients at acute high risk typically require hospitalization and encouraging your client to consider this will be the immediate concern. Your goal is always to collaborate with your client and facilitate the least invasive way they can access hospital care. Any involuntary actions should always be considered as a last resort and only when all other options have been exhausted. [An additional post will explore imminent risk further and the path to hospitalization - both voluntary and involuntary]
Essential Features
Suicide DESIRE with INTENT and CAPABILITY
Even if BUFFERS are present, they are likely insufficient
Unwilling or unable to develop a safety plan or to address access to lethal means
Assessment Presentation
Will likely express thoughts of suicide and have a plan - may have engaged in preparatory behaviors
Capability to act may be enhanced by having a history of attempts in addition to access to means
Likely be unable to sufficiently establish a safe environment due to emotional distress or high intent
May be experiencing acute psychosocial stressors (e.g., job loss, relationship dissolution, relapse on alcohol)
May be highly dysregulated with no real coping skills
In 988 training, someone at high acute risk of suicide would be considered as being at “imminent risk” requiring an intervention
988 Definition of Imminent Risk:
An individual is determined to be at imminent risk of suicide if …….there is a close temporal connection between the person’s current risk status and actions that could lead to their suicide (risk and potential actions are essentially close in time)
The risk must be present in the sense that it creates an obligation and immediate pressure to take urgent actions to reduce the individual’s risk; that is, if no actions are taken, the individual is likely to seriously harm or kill themselves.
Imminent Risk may be determined if an individual states both a desire and intent to die and has the capability of carrying through on this intent.
Considering Hospitalization
The following are some situations where you may consider hospitalization
Your risk formulation indicates High Acute Risk
Suicide DESIRE with INTENT and CAPABILITY
Even if BUFFERS are present, they are likely insufficient
Unwilling or unable to develop a safety plan or to address access to lethal means
Your client expresses suicide DESIRE and and has been recently discharged from a hospital or ER following a suicide attempt
This period immediately post-discharge is one of the highest risk periods so any client continuing to express suicide desire after discharge should be considered a significant risk for reattempting
Your client acknowledges that they don't feel safe and would like to be in a hospital
Your client reports command hallucinations to harm themselves
Voluntary Actions
Once your client agrees that hospitalization is the best way to get the support they need, it is important to ensure they clearly understand the next steps. It's always best to reiterate the decision clearly so they understand that you both feel that it is in their best interest that they go to a hospital.
In contacting emergency services, the following are steps I consider in my practice that may be helpful:
Planning to Call 911:
Ask your client if there is anyone they would like you to inform or anyone they feel could accompany them to (or meet them at) the ER.
Inform them that you will call 911 and have them taken via ambulance.
Even if your client has someone to accompany them, it is usually best to have an ambulance transport them to the emergency room. Your client will be taken to triage quicker and you also avoid the risk that they change their mind on the way to the hospital and pressure a friend to take them home. This, of course, could lead to significant problems should their thoughts of suicide continue and that friend cannot be with them - or they do not return home and you are unable to contact them.
If time allows, obtain your client’s consent for contact with ER
Note - you do not need consent to speak with emergency room staff upon your client’s arrival to discuss your assessment, client risk status, and need for evaluation/hospitalization (see note on HIPAA below) - but a consent form can be useful should you need to maintain ongoing discussions with the treatment team.
Calling 911:
When you call 911, inform the operator that you are a mental health professional and have a client in your office who is at risk of suicide and needs to be transported to an emergency room.
Clearly state that the client is in agreement and that there are no weapons present.
When EMTs arrive ask where they plan to take your client - which emergency room.
People are not always transported to the nearest ER which may depend on how busy local ERs are or which hospital has a Psych ER.
After Calling 911:
Contact the emergency room where your client is being taken and inform Nurse/Social Worker/MD of your assessment and concerns.
People often change their stories once they arrive at a hospital. This can be frustrating for a clinician but emergency rooms can feel overwhelming and your client may feel scared or less acute than others they see in the emergency setting and rethink the decision. They can often minimize concerns.
Be sure to leave your contact information with ER staff for follow-up
Involuntary Actions
Attending to a client's need for hospitalization can be stressful - even when your client agrees it is the best course of action. But what if, in your risk formulation, you have determined that your client is a high acute risk: they have been unable to work with you to mitigate risk, there are no buffers present, and you believe hospitalization is your only option - but the client refuses? What options do you have then?
If working with a client in person, the chances are, if they believe you are intent on contacting 911 and they do not want you to intervene, they will leave your office. In remote sessions, they may simply hang up - and possibly leave the location.
In this situation, the following are steps I consider in my practice that may be helpful:
Reach Out to Emergency Contact:
Immediately reach out to your client's emergency contact and inform them of your concerns regarding their risk status.
You may be able to develop a plan with this contact to monitor your client and it is also an opportunity to discuss any potential access to lethal means and to work to try to make the home safer. It is also important to make sure they have the 988 number.
Call 988
If you cannot reach your client’s contact (and probably even if you can) you can also contact 988, inform them of the risk status of your client, and ask for assistance. 988 crisis counselors can
Attempt to reach out to the individual (to do a further assessment of risk status)
Request a mobile crisis team visit (the team can go to your client's home - here dispatch time will depend on the specific team as all crisis teams are different - and they will want to know if the client is home)
Dispatch emergency services (if they do connect with the individual they can dispatch emergency services - should they also have deemed the situation acute high risk - imminent risk - and will do their best to trace your client’s location (this may or may not be possible))
Request a wellness check (where local police can go to the person’s address and attempt to assess their welfare)
Call 911
Call 911 yourself to provide information on your client’s risk.
This is only useful if you know your client’s current location. You can also directly request a welfare check.
Undertaking an involuntary action may be all you can do when you believe that if you don’t intervene there is a high risk of suicide. I will emphasize, however, that your involuntary action does not guarantee hospitalization or an appropriate intervention. While you may often hear guidance to "err on the side of caution", involuntary actions are not without consequences that must be considered and I would pursue this option only after all other avenues have been explored and as an absolute last resort. In the next post, I will discuss further the impact of involuntary actions as well as why crisis lines (such as 988) have committed to pursue this option when a person is at high risk of suicide.
Involuntary actions are not without consequences and should only be considered as an absolute last resort
* About HIPAA: The HIPAA Privacy Rule permits a covered entity to disclose PHI, including psychotherapy notes, when the covered entity has a good faith belief that the disclosure: (1) is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others and (2) is to a person(s) reasonably able to prevent or lessen the threat. This may include, depending on the circumstances, disclosure to law enforcement, family members, the target of the threat, or others who the covered entity has a good faith belief can mitigate the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR § 164.512(j)(1)(i).
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