"Working With Suicidal Patients" was a workshop I presented for The Maple Counseling Center in Beverly Hills, CA. Please feel free to view or download. -Mark Allison

1. Working with
Suicidal Patients
Suicide Risk Assessment
M a p l e C o u n s e l i n g
C e n t e r
M a r k A l l i s o n
www.thebeverlyhillstherapist.com 1

2. What we will cover in this
workshop
History of the suicide crisis intervention lines
What the bleep do you know about suicide?
Suicide Facts Vs. Myths
Legal vs. Ethical practice
Risk Assessment: Assessing for Lethality
Interventions
Role Play
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3. History of Suicide
Prevention Hotlines
The Los Angeles Suicide Prevention Center
(SPC) founded in 1958,was the first agency of
its kind to establish a crisis line offering round
the clock telephone counseling to people in
suicidal crisis.
SPC's telephone intervention model has been
adopted by most crisis centers and hotlines
across the nation and throughout the world.
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4. www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

5. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
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6. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

7. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

8. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

9. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
3. Most suicides are committed by drug overdose?
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

10. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
3. Most suicides are committed by drug overdose?
Actually, most suicides are by gun shot.
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

11. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
3. Most suicides are committed by drug overdose?
Actually, most suicides are by gun shot.
4. In the US, Suicides occur most frequently in the Spring?
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

12. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
3. Most suicides are committed by drug overdose?
Actually, most suicides are by gun shot.
4. In the US, Suicides occur most frequently in the Spring?
True, People die by suicide more often during spring and summer. The
idea that suicide is more common in the winter holidays is a
misconception.
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

13. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
3. Most suicides are committed by drug overdose?
Actually, most suicides are by gun shot.
4. In the US, Suicides occur most frequently in the Spring?
True, People die by suicide more often during spring and summer. The
idea that suicide is more common in the winter holidays is a
misconception.
5. It’s best not to talk about suicide to a depressed client?
www.thebeverlyhillstherapist.com 4 ©Mark Allison 2010

14. what the bleep do you know
about suicide!
1. More women than men attempt suicide?
Women attempt suicide three times as often as men, though men
Die by suicide four times as often as women.
2. More people die by suicide than by homicide?
30,000 die by suicide, 20,000 by homicide
3. Most suicides are committed by drug overdose?
Actually, most suicides are by gun shot.
4. In the US, Suicides occur most frequently in the Spring?
True, People die by suicide more often during spring and summer. The
idea that suicide is more common in the winter holidays is a
misconception.
5. It’s best not to talk about suicide to a depressed client?
Many depressed people have already considered suicide as an option
Discussing it openly helps the suicidal person sort through the problems
And generally provides a sense of relief and understanding.
www.thebeverlyhillstherapist.commost helpful things you can do.
It’s one of the 4 ©Mark Allison 2010

15. www.thebeverlyhillstherapist.com 5 ©Mark Allison 2010

16. what the bleep do you know
about suicide!
6. In California, if a client tells a therapist that he is going to kill himself,
the therapist, by law, must report it?
www.thebeverlyhillstherapist.com 5 ©Mark Allison 2010

17. what the bleep do you know
about suicide!
6. In California, if a client tells a therapist that he is going to kill himself,
the therapist, by law, must report it?
Kinda of False. In California, the law does not require a licensed
therapist to report a suicide threat by their patient.
Two conditions where it is mandatory:
1. A minor or student at a school
2. If Client threatens to take his own life along with another person
and the indented victim is reasonably identifiable.
www.thebeverlyhillstherapist.com 5 ©Mark Allison 2010

18. what the bleep do you know
about suicide!
6. In California, if a client tells a therapist that he is going to kill himself,
the therapist, by law, must report it?
Kinda of False. In California, the law does not require a licensed
therapist to report a suicide threat by their patient.
Two conditions where it is mandatory:
1. A minor or student at a school
2. If Client threatens to take his own life along with another person
and the indented victim is reasonably identifiable.
7. Suicide rates are generally higher than the national average in the
Western states and lower in the Eastern and Midwestern states?
www.thebeverlyhillstherapist.com 5 ©Mark Allison 2010

19. what the bleep do you know
about suicide!
6. In California, if a client tells a therapist that he is going to kill himself,
the therapist, by law, must report it?
Kinda of False. In California, the law does not require a licensed
therapist to report a suicide threat by their patient.
Two conditions where it is mandatory:
1. A minor or student at a school
2. If Client threatens to take his own life along with another person
and the indented victim is reasonably identifiable.
7. Suicide rates are generally higher than the national average in the
Western states and lower in the Eastern and Midwestern states?
True, According to NAMI, it is highest in the western states...
www.thebeverlyhillstherapist.com 5 ©Mark Allison 2010

20. what the bleep do you know
about suicide!
6. In California, if a client tells a therapist that he is going to kill himself,
the therapist, by law, must report it?
Kinda of False. In California, the law does not require a licensed
therapist to report a suicide threat by their patient.
Two conditions where it is mandatory:
1. A minor or student at a school
2. If Client threatens to take his own life along with another person
and the indented victim is reasonably identifiable.
7. Suicide rates are generally higher than the national average in the
Western states and lower in the Eastern and Midwestern states?
True, According to NAMI, it is highest in the western states...
8. Young people who are suicidal often give warning signs
www.thebeverlyhillstherapist.com 5 ©Mark Allison 2010

21. what the bleep do you know
about suicide!
6. In California, if a client tells a therapist that he is going to kill himself,
the therapist, by law, must report it?
Kinda of False. In California, the law does not require a licensed
therapist to report a suicide threat by their patient.
Two conditions where it is mandatory:
1. A minor or student at a school
2. If Client threatens to take his own life along with another person
and the indented victim is reasonably identifiable.
7. Suicide rates are generally higher than the national average in the
Western states and lower in the Eastern and Midwestern states?
True, According to NAMI, it is highest in the western states...
8. Young people who are suicidal often give warning signs
True.
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22. www.thebeverlyhillstherapist.com 6 ©Mark Allison 2010

23. what the bleep do you know
about suicide!
9. Most deaths by suicide can be prevented
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24. what the bleep do you know
about suicide!
9. Most deaths by suicide can be prevented
True. Well...kind of....
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25. what the bleep do you know
about suicide!
9. Most deaths by suicide can be prevented
True. Well...kind of....
10. The most important predictor of suicide attempt is the presence
of a specific detailed plan, no matter what age or sex the
person is.
www.thebeverlyhillstherapist.com 6 ©Mark Allison 2010

26. what the bleep do you know
about suicide!
9. Most deaths by suicide can be prevented
True. Well...kind of....
10. The most important predictor of suicide attempt is the presence
of a specific detailed plan, no matter what age or sex the
person is.
True, a detailed specific plan should alarm a therapist that
patient is at a higher lethality risk.
www.thebeverlyhillstherapist.com 6 ©Mark Allison 2010

27. facts and myths about Suicide
Some Statistics
• Suicide took the lives of 32,637 people in 2005 (CDC 2008)
• Suicide is the 11th ranking cause of death in the US 3rd for young. (McIntosh,
2005).
• 816,000 annual attempts in US. Translates to one attempt every 39 seconds
(CDC 2004).
• In 2001, 55% of suicides were committed with a firearm (Anderson and Smith
2003).
Groups at Risk
• 3 Female attempts to every male attempt.
• Males are four times more likely to die from suicide than females (CDC 2004).
• Suicide is the eighth leading cause of death for all U.S. men (Anderson and
Smith 2003).
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28. facts and myths about Suicide
Myth
Suicidal people just want to die.
Fact
Most of the time, suicidal people are torn between wanting to die and
wanting to live. Most suicidal individuals don't want death; they just want
to stop the great psychological or emotional pain they are experiencing.
Myth
People who commit suicide do not warn others.
Fact
Eight out of every 10 people who kill themselves give definite clues to
their intentions. They leave numerous clues and warnings to others,
although clues may be non‐verbal or difficult to detect.
Myth
People who talk about suicide are only trying to get attention. They won't
really do it.
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29. facts and myths about Suicide
Fact
Few commit suicide without first letting someone know how they feel. Those
who are considering suicide give clues and warnings as a cry for help. Over
70% who do threaten to commit suicide either make an attempt or complete
the act.
Myth
Don't mention suicide to someone who's showing signs of depression. It will
plant the idea in their minds and they will act on it.
Fact
Many depressed people have already considered suicide as an option.
Discussing it openly helps the suicidal person sort through the problems and
generally provides a sense of relief and understanding. It is one of the most
helpful things you can do.
www.thebeverlyhillstherapist.com 9 ©Mark Allison 2010

30. Legal & Ethical Issues
In California, the law does not require a licensed therapist to
report a suicide threat by their patient. However Evidence
Code 1024 protects the therapist if they report it.
We do however have a legal and ethical duty to take
“reasonable steps” to ensure the safety of suicidal clients”
Two conditions where the law would require to report:
1. A minor, a student at school.
2. If client threatens to take his own life and the life of
another person and the intended victim is reasonably
identifiable.
www.thebeverlyhillstherapist.com 10 ©Mark Allison 2010

31. Legal & Ethical Issues
If therapist does decide to break confidentiality to report
a suicide threat or ideation. Evidence Code 1024 protects
the therapist.
Evidence Code 1024: if psychotherapist has reasonable
cause to believe that patient is in such mental or
emotional condition as to be dangerous to him/herself or
to the person or property of another and that disclosures
of communication is necessary to prevent the threatened
danger
Therapist can contact authorities who will initiate a:
5150: 72 hour involuntary hold.
5250 14 day hold
5260 14 additional days
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32. What is the point of
this?
It’s not about how to stop a suicidal patient
who didn’t reach out...
but how to prevent a potential suicide from a
patient who tried to reach out or presented
with symptoms and warning signs.
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33. Listen!
Our job as therapists is to be listening to our
patients...
A suicidal patient wants to be heard...
LISTEN
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34. Empathy Vs. Sympathy
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35. Empathy Vs. Sympathy
Sympathy
Kindness of feeling toward one who suffers; pity;
commiseration; compassion.
Empathy
The ability to understand and share the feelings of
another
‐Oxford American Dictionary
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36. Talking to Suicidal
Patients
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37. Talking to Suicidal
Patients
Gathering information questions should be
interspersed with rapport building statements
Listen to the answer, follow up with an an
empathic statement when appropriate and let
that direct your next question
Don’t be alarmed by their thoughts of suicide
Model discussing it openly
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38. Talking to suicidal
patients on the phone
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39. Talking to suicidal
patients on the phone
Listen using Active Listening skills. The suicidal person
often needs to be heard
Refrain from saying, “it’s going to be ok” or “tomorrow
will be a new day”
Avoid searching for quick solutions
Always try to be assessing for lethality.
Close call with a follow up assessment:
i.e. “I’m wondering when I get off the phone what you plan on doing”
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40. Talking to suicidal
patients on the phone
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41. Talking to suicidal
patients on the phone
Empathic voice, try to voice match
Use open ended questions (to encourage
expression of feelings and to build rapport)
Ask the suicide question directly:
Ask “Are you thinking about killing yourself
tonight”
Rather than, “Are you thinking about doing
something”
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42. Lethality assessment
begins at intake
Read through your completed intake before
your first session with patient.
Look for warning signs that may indicate
suicidal risk.
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43. Open ended
questions
Closed Ended
Caller: I just can’t take it anymore, I don’t
know what I am going to do after what
she said to me last night
Therapist: What are you doing to do? or
“Are you angry at someone?
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44. open ended
questions
Open Ended
Caller: “I just can’t take it anymore, I feel
like there is no way out”
Therapist: “It sounds like you are feeling
overwhelmed. This must be a really difficult
time for you right now.”
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45. closed ended
questions
When would we ask closed ended questions?
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46. closed ended
questions
When would we ask closed ended questions?
Lethality Assessment:
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47. closed ended
questions
When would we ask closed ended questions?
Lethality Assessment:
Are you thinking about killing yourself?
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48. closed ended
questions
When would we ask closed ended questions?
Lethality Assessment:
Are you thinking about killing yourself?
How were you planning on killing
yourself?
www.thebeverlyhillstherapist.com 21 ©Mark Allison 2010

49. closed ended
questions
When would we ask closed ended questions?
Lethality Assessment:
Are you thinking about killing yourself?
How were you planning on killing
yourself?
Do you have access to a gun?
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50. flow and followup
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51. flow and followup
Questions should flow in a direction
Try to explore one area at a time
Listen to the clients’s answer before preparing
your next question
Be sensitive to how your question may be
perceived.
i.e. “Have you always be so depressed?”
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52. Warning signs
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53. Warning signs
Expressing suicidal feelings directly or bringing up the topic of
suicide
Giving away prized possessions, settling affairs, making out a
will
Signs of depression: loss of pleasure , sad mood, alteration in
sleeping/eating patterns, feelings of hopelessness and excessive
guilt
Change of behavior (poor work or school performance)
Risk‐taking behaviors
Increased use of alcohol or drugs
Social Isolation
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54. What’s The Number 1
Warning sign
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55. What’s The Number 1
Warning sign
Developing a specific plan for suicide
This is the NUMBER ONE predictor of suicide
risk!
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56. Risk factors
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57. Risk factors
Having attempted suicide in the past
Signs of depression, prolong sadness, feelings
of hopelessness, deep apathy
Eating problems
Anguish over recent loss
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58. Suicide Risk assessment
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59. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
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60. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
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61. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

62. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

63. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
5. Have they been drinking or intoxicated (drugs street or prescription)
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

64. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
5. Have they been drinking or intoxicated (drugs street or prescription)
6. Have they ever attempted to kill themselves before
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

65. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
5. Have they been drinking or intoxicated (drugs street or prescription)
6. Have they ever attempted to kill themselves before
7. Is there a gun in the home? Number 1 method for completed suicides
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

66. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
5. Have they been drinking or intoxicated (drugs street or prescription)
6. Have they ever attempted to kill themselves before
7. Is there a gun in the home? Number 1 method for completed suicides
8. Family History of suicide and/or depression
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

67. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
5. Have they been drinking or intoxicated (drugs street or prescription)
6. Have they ever attempted to kill themselves before
7. Is there a gun in the home? Number 1 method for completed suicides
8. Family History of suicide and/or depression
9. Medications
www.thebeverlyhillstherapist.com 26 ©Mark Allison 2010

68. Suicide Risk assessment
1. Are they thinking about killing themselves? (ask directly)
2. Do they have a plan? When?
3. Do they have the means to commit suicide at their hands?
4. Are they alone?
5. Have they been drinking or intoxicated (drugs street or prescription)
6. Have they ever attempted to kill themselves before
7. Is there a gun in the home? Number 1 method for completed suicides
8. Family History of suicide and/or depression
9. Medications
10.Mental illness
www.thebeverlyhillstherapist.com - Diagnosis 26 ©Mark Allison 2010

69. Suicide
ESIRE AP ABILITY risk
Ideation
Psych Pain
Priors Attempts
Available Means
assessment
Hopeless/Helpless Survivor
Burden Violence
Trapped Intoxicated/Sub. Abuse
Alone Mood Change/Out of Touch
Anxiety/Insomnia
NTENT UFFERS
Specific Plan Immediate Supports
Preparatory Behaviors Social Supports
Intent To Die - Planning For The Future
Engaged With Counselor
Ambivalence For Life/Death
Core Values/Beliefs
Sense Of Purpose
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70. assessment tool
Desire
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71. assessment tool
Desire
Suicidal Ideation
Psychological Pain
Feeling Trapped
Feeling Alone
Hopelessness
Helplessness
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72. assessment tool
Capability
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73. assessment tool
Capability
Previous Attempts
Exposure to Someone’s Else’s Suicide
Violence (past or present)
Availability of Means
Currently Intoxicated
Substance Abuse
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74. assessment tool
Capability
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75. assessment tool
Capability
Mood Change
Anxiety
Decreased Sleep
Out of Touch
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76. assessment tool
Intent
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77. assessment tool
Intent
Suicide Plan
Preparatory Behaviors
Expressed Intent to die
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78. assessment tool
Buffers/connectedness
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79. assessment tool
Buffers/connectedness
Immediate Supports
Social Supports
Engagement
Core Values and Beliefs
Sense of Purpose
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80. assessment tool
Buffers/connectedness
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81. assessment tool
Buffers/connectedness
Future Plans
Ambivalence for Living/Dying
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82. Risk Assessment
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83. Risk Assessment
Is there a “message” that they are sending by
their suicide?
Is there any desired outcome (reunion with
deceased relatives, guilty feelings reduced or
engendered, burden being lifted)?
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84. Lethality assessment
summary
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85. Lethality assessment
summary
1. Ask directly are they having thoughts about killing themselves
2. Do they have a plan? How specific is it? When?
3. Is there access to the means?
4. Have they thought about suicide in the past 2 months?
5. Are they drinking/under the influence?
6. Recent or prior attempts?
7. Are they alone?
8. Family history of suicide and or depression?
9. Mental Illness (Major Depression Disorder,Bi‐polar etc)?
10.Are they on any medications?
11.Do they have a gun or access to a gun?
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86. Interventions
Start with the least intrusive intervention first
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87. Interventions
“No Suicide” Contract
Increased client contact
Collaborative “Action Plan”
Organize a 24‐hour suicide watch among family
and friends
Help to arrange for a voluntary hospitalization
Initiate involuntary hospitalization (5150)
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88. Vignettes
Questions
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89. concluding
thoughts
Develop understanding and trust
Listen for words and feelings that indicate
suicidal thoughts.
Assess for suicide using suicide risk
assessment technique
Develop direction and focus
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90. A Good referral
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91. A Good referral
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92. Role Play
Question Period
Conclusion
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93. End
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