Read the three scenarios below carefully. For each scenario, complete an abbreviated suicide risk assessment and intervention form using the attached template. Determine the client’s risk level by analyzing the person’s desire, intent, capability, and buffers, then document what an ideal plan of action would be based on their risk level (HINT: See the intervention chart in the Week 3 guided reading). For the purposes of this assignment, you should assume that the client is willing to acknowledge ambivalence.

Scenario A: Sal is 62 years old and recently retired from his job as a police captain in a small suburban town. He took an early retirement because his wife recently died of liver cancer and also because of a knee injury he sustained about five years ago. He has been seeing you for grief counseling since the loss of his wife, but today he seems more upbeat than usual. Sal still experiences a lot of pain from his injured knee. He has been given Percocet for pain, which he will often take in order to get to sleep. Sal was very proud of being a policeman and feels he has been “useless” since his injury. He did feel good about taking care of his wife during her battle with cancer but feels lonely and empty since she died. Sal visits her grave every day and says he cannot wait until he “joins” her. Sal still sees some of his coworkers from the police department and every so often they will go to the shooting range together. He mentions that he has been clearing out his home, saying “I don’t want my kids to have to deal with all that junk when I’m gone.” When you ask him about suicide he admits to some ideation but denies having a specific plan.

Scenario B: Maria is a 19-year-old college student in her sophomore year. She told her roommate that she has been feeling depressed over problems she was having with her boyfriend. Recently, Maria found out that her boyfriend was cheating on her with a mutual friend. When she confronted her boyfriend, he denied the accusations and told Maria that she was “just being paranoid and crazy,” but seized the moment to break up with her. Maria is feeling angry, sad, and hopeless. She won’t get out of bed and has been missing classes. She did well in her freshman year but is receiving a scholarship and is afraid that if her grades drop she’ll lose the scholarship which means that she’ll have to return home and attend a local community college. Maria reports that she feels overwhelmed. She thinks that nothing she does will make things any better. She reached you by calling the hotline of a mental health clinic today because she felt so “upset” that she was considering taking her roommate’s prescription medication and washing it down with vodka. Maria mentions to you that she was in counseling while she was in high school after her parents separated. Maria describes feeling “lifeless and hopeless,”  having no energy or motivation to do anything. She also reports that nothing is really enjoyable to her anymore and that as a result, she has become increasingly reclusive, preferring to be alone. Maria also states that she has not been eating or sleeping very well. She states that since the problems with her boyfriend began she feels she doesn’t have anything to live for.

Scenario C: Beth is a 24-year-old separated mother of a 10-month-old daughter. She called the hotline of the local mental health clinic today because she felt so depressed that she could not get out of bed.  Beth explained to the hotline crisis worker that she has felt this way for the past six months. Beth described feeling hopeless and says that she has no energy to do anything. She also said that nothing is really enjoyable to her anymore, and as a result, she has become increasingly reclusive and prefers to be left alone. Since Beth’s husband left her to run off with one of her best friends, Beth thinks  she doesn’t “have anything to live for.” When questioned directly about suicide she admits to “thinking that at least death would take this pain away,” but denies intent. She later mentions that she tried to cut her wrists a few days ago when she received a copy of the divorce papers, but “lost the nerve” and could not go through with it. “Besides,” she said, “I could never leave my baby all alone, with no one to look out for her.” 

Watch this video: 

https://youtu.be/ENN50LGdwbg

1. What risk factors did Jake have for violence?

2. What did you think the counselor did well?

3. What would you do differently? (you cannot answer that you would not change anything)

on time

Student Name:

Week 4 Assignment Template

Part 1 – Suicide Risk Assessment and Intervention

Scenario A, Sal

Notes:

Notes:

Notes:

		Desire ☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness ☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone
											Notes:
		Capability ☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage ☐History of/current self-harm or violence toward others ☐Availability of means ☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness
		Intent ☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent ☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan
		Buffers/Connectedness ☐Immediate supports ☐Social supports ☐Planning for the future ☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose ☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Risk level

☐Low Risk (desire only)

☐Low-Moderate Risk (desire + capability + numerous buffers)

☐Moderate Risk (desire + capability)

☐Moderate-High Risk (desire + capability + intent + numerous buffers)

☐High Risk (desire + capability + intent)

		Plan of Action · The Plan of Action should be as detailed as possible and driven by the client. · The checkboxes below are to guide you. You should detail each step in the numbered section. ☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means ☐Involve family or other social supports ☐Verbal no-suicide/violence agreement ☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)
		1. 2. 3. Add more steps if needed

Scenario B, Maria

Desire
☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness
☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability
☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage
☐History of/current self-harm or violence toward others ☐Availability of means
☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent
☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent
☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness
☐Immediate supports ☐Social supports ☐Planning for the future
☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose
☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Risk level
☐Low Risk (desire only)
☐Low-Moderate Risk (desire + capability + numerous buffers)
☐Moderate Risk (desire + capability)
☐Moderate-High Risk (desire + capability + intent + numerous buffers)
☐High Risk (desire + capability + intent)

Plan of Action
· The Plan of Action should be as detailed as possible and driven by the client.
· The checkboxes below are to guide you. You should detail each step in the numbered section.
☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means
☐Involve family or other social supports ☐Verbal no-suicide/violence agreement
☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.
2.
3.
Add more steps if needed

Scenario C, Beth

Desire
☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness
☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability
☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage
☐History of/current self-harm or violence toward others ☐Availability of means
☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent
☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent
☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness
☐Immediate supports ☐Social supports ☐Planning for the future
☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose
☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Risk level
☐Low Risk (desire only)
☐Low-Moderate Risk (desire + capability + numerous buffers)
☐Moderate Risk (desire + capability)
☐Moderate-High Risk (desire + capability + intent + numerous buffers)
☐High Risk (desire + capability + intent)

Plan of Action
· The Plan of Action should be as detailed as possible and driven by the client.
· The checkboxes below are to guide you. You should detail each step in the numbered section.
☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means
☐Involve family or other social supports ☐Verbal no-suicide/violence agreement
☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.
2.
3.
Add more steps if needed

Part 2 – Violence Risk Assessment and Intervention

What risk factors did Jake have for violence?

What did you think the counselor did well?

What would you do differently? (you cannot answer that you would not change anything.)

Description

Week3 centers around four main topics:

1) Suicide assessment and intervention

2) Violence assessment and intervention

3) Safety in the field of crisis intervention

4) Social worker self-care

A major component of assessment in crisis intervention centers around safety. In Week 3, we will be discussing suicide
and violence intervention and assessment. You will learn how to assess clients for their risk for completing suicide
and/or homicide and to plan and deliver appropriate and e�ective interventions based on the client’s risk level. You will
also learn strategies for maximizing crisis worker safety and practicing self-care.

Be sure to take care of yourself this week- the material we will cover is heavy and may be triggering for some students.
Use your coping skills and social supports and seek professional counseling if needed.

Table of contents

1. Suicide

1.1. Definitions and Terminology

1.2. Scope

1.3. Suicide Myths

1.4. Risk and Protective Factors

1.5. Suicide and the ABC Model

1.6. Suicide Risk Assessment

1.7.

Suicidal Ambivalence

1.8. Suicide Intervention

1.9. Hospitalization

1.10. Observe a Suicide Intervention Role Play

1.11. How Social Supports Can Help

2. Violence

2.1. Scope

2.2. Risk Factors

2.3. Violence Assessment & Intervention

3. Legal and Ethical Considerations for Crises of Lethality

4. Social Worker Safety in the Workplace

4.1. Improving Workplace Safety

4.2. De-Escalation Techniques

5. Social Worker Self-Care

1. Suicide

The first chapter of this Guided Reading will focus on suicide assessment and intervention.

 

Before we get started, I’d like you to take the time to listen to or read the transcript of this podcast (it’s 19
minutes long). The intended audience is the general population, not mental health professionals, but it really
sets the tone for the supportive and collaborative approach we are going to take to suicide intervention in this
course

If the embedded widget above does not work for you, you can find the audio and transcript here. 

Maria Fabrizio for NPR
© 2020 npr

share

shots – health news

Reach Out: How To Help Someone At
Risk Of Suicide

listen 19:26

https://www.npr.org/transcripts/707686101

https://www.npr.org/sections/health-shots/2019/04/20/707686101/how-to-help-someone-at-risk-of-suicide

https://www.npr.org/sections/health-shots/2019/04/20/707686101/how-to-help-someone-at-risk-of-suicide

https://www.npr.org/sections/health-shots/

https://www.npr.org/sections/health-shots/2019/04/20/707686101/how-to-help-someone-at-risk-of-suicide

1.1. De�nitions and Terminology

Suicide is a personal and family tragedy as well as a public health issue. To begin thinking about suicide
intervention and prevention, it is helpful to learn basic definitions, statistics regarding the problem, and risk and
protective factors for the problem. Let’s begin with watching the video from the US Center for Disease Control
about suicide.

Before we move forward, let’s discuss some suicide-related terminology.

This website provides a helpful glossary of suicide-related terms. 

 

It is preferred NOT to use the phrase “committed suicide.” This has a negative connotation, such as “committed a
crime” or “committed a sin.”

The preferred terms are: “completed suicide” or “died by suicide.”

 

https://www.sprc.org/about-suicide/topics-terms

“Survivors of suicide” refer to loved ones of people who died by suicide, NOT people who have survived a
suicide attempt. People who attempted suicide and survived are called “suicide attempt survivors.”

Grieving a person who died by suicide is o�en complicated and is di�erent from grieving people who have died
by other causes. We will discuss this in more detail in Week 5, when we cover grief and loss. Also, knowing
someone who has died by suicide is a key risk factor for completing suicide. 

1.2. Scope

Suicide is a major public health issue that a�ects all groups of people, regardless of age, gender, race, ethnicity,
sexual orientation, or other categorization. However, some groups have notable rates and trends of completion
and attempts. 

This section has two purposes: 

1) To expose you to credible sources for information about suicide. Social workers are responsible for remaining
up-to-date on research and evidence-based practices to inform their practice. This “scavenger hunt” activity will
bring you to some key, professional online sources regarding suicide. 

2) To provide information about the scope of the problem of suicide. While exploring these sources, you will be
looking for some key facts about the prevalence, risk factors, and protective factors for suicide. Statistics in
textbooks are o�en out of date. These websites provide statistics from more recent data. 

Use the sources provided (and your own web searches, if needed) to fill in the blanks for the facts about
suicide. 

Sources 

American Association of Suicidology

American Foundation for Suicide Prevention

Center for Disease Control and Prevention

Check out statistics specific to your state. 

Check out statistics by occupation. 

National Action Alliance for Suicide Prevention

National Suicide Prevention Lifeline 

Suicide Prevention Resource Center

Facts 

Suicide is the _______ leading cause of death in the United States.

The rate of suicide is highest in _________ (race) ____________ (age)_____________(sex)

Men died by suicide ______ times more than women. Women attempted suicide ______times more than men. 

Rate of suicide for veterans is ______times that of non-veterans. 

Firearms accounted for _________% of all suicide deaths

2nd most common method for suicide: ___________________

3rd most common:___________________

The highest rate of suicide was among this age group: _________________

2nd highest rate by age group: ____________________

How do adolescents and young adults (15 to 24) rates compare to these groups’ rates? 

Home

https://afsp.org/

https://www.cdc.gov/violenceprevention/suicide/index.html

https://afsp.org/about-suicide/state-fact-sheets/

https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a1.htm?s_cid=mm6745a1_w

https://theactionalliance.org/

https://suicidepreventionlifeline.org/

Suicide Prevention Resource Center

 

Suicide is the ________ leading cause of death for people ages 10 to 34

Suicide is the ________ leading cause of death for people ages 35 to 54

Which occupational group has the highest rate of suicide for women? For men?

How does the Health and Social Services (i.e., social workers!) occupational group’s rates of suicide compare to
other occupational groups? 

What geographic areas in the United States have the highest rates of suicide?

What racial/ethnic groups have the highest rates of suicide? 

What factors may put LGBTQ individuals a higher risk for suicide?

1.3. Suicide Myths

There are many myths surrounding suicide. These misconceptions can be dangerous—so it is important as a
mental health professional to have accurate information so that we can educate our clients and the public.
Below are some common myths about suicide. 

1.     Discussing suicide will cause the client to move toward doing it.

2.     Clients who say they want to kill themselves don’t do it.

3.     Suicide is an irrational act.

4.     People who complete suicide are insane.

5.     Suicide runs in families—it is an inherited tendency.

6.     Once suicidal, always suicidal.

7.     When a person has attempted suicide and pulls out of it, the danger is over.

8.     A suicidal person who begins to show generosity and share personal possessions is showing signs of
renewal and recovery.

9.     Suicide is always an impulsive act.

10.  Suicide strikes only the rich.

11.  Suicide happens without warning.

12.  Suicide is a painless way to die.

13.  Few professional people kill themselves.

14.  Christmas season is lethal.

15.  Women don’t use guns to attempt suicide because of the risk of disfigurement if not complete.

16.  More suicides occur during a full moon.

17.  Suicidal people rarely seek medical attention.

18.  Most elderly people who complete suicide are terminally ill.

19.  Suicide is limited to the young.

20.  Suicidal thoughts are relatively rare. 

REFLECT: Which of these myths are surprising to you? Were there any ones that you have held yourself? Also,
think about the position that you hold on suicide, the feelings that arise when you think about suicide. How
might these attitudes and beliefs a�ect your work as a social worker for people in crisis? 

1.4. Risk and Protective Factors

There are factors that put a person at risk for completing suicide–these are called risk factors. Factors that
bu�er against these risk factors and reduce a person’s risk for completing suicide are called protective factors.
The chart below lists key risk and protective factors identified by the Suicide Prevention Resource Center. 

Risk Factors Protec�ve Factors

• Availability of lethal means, especially firearms.

• Few available sources of suppor�ve rela�onships.

• High-conflict or violent rela�onships.

• Family history of suicide.

• Mental illness.

• Substance abuse.

• Previous suicide a�empt.

• Impulsivity or aggression.

• Media portrayals of suicide

• Barriers to health care, such as lack of access to providers or
medica�ons.

• History of physical, sexual, and/or mental abuse.

• Life loss or crisis, such as a death or the loss of a rela�onship or
job.

• Serious illness

• Survivor of suicide

• Availability of physical and mental health care.

• Crea�on of safe prac�ces to mi�gate lethal means of suicide.

• Safe and suppor�ve school and community environments.

• Sources of con�nued care a�er psychiatric hospitaliza�on.

• Connectedness to individuals, family, community, and social
ins�tu�ons

• Suppor�ve rela�onships with health care providers; engagement
with crisis worker.

• Coping & problem solving skills

• Reasons for living (ex: children)

• Cultural and religious beliefs that discourage suicide

Risk factors are di�erent than warning signs. If a person has many risk factors, this may trigger a need to
conduct a suicide assessment even the person denies any suicidal ideation or plans. Warning signs should
always trigger a suicide assessment. The following is a list from the American Foundation of Suicide Prevention.  

Talk Behavior Mood

If a person talks about:

Killing themselves
Feeling hopeless
Having no reason to live
Being a burden to others

Feeling trapped

Unbearable pain

Behaviors that may signal risk, especially
if related to a painful event, loss or
change:

Increased use of alcohol or drugs
Looking for a way to end their lives, such as
searching online for methods
Withdrawing from ac�vi�es
Isola�ng from family and friends
Sleeping too much or too li�le
Visi�ng or calling people to say goodbye
Giving away prized possessions
Aggression
Fa�gue

People who are considering suicide
o�en display one or more of the
following moods:

Depression
Anxiety
Loss of interest
Irritability
Humilia�on/Shame
Agita�on/Anger
Relief/Sudden Improvement

https://afsp.org/about-suicide/risk-factors-and-warning-signs/

1.5. Suicide and the ABC Model

Assessing for suicide is an important part of ABC Model of Crisis Intervention. If you suspect that a client may be
considering suicide, you should incorporate suicide assessment into the B stage (Exploring the Problem).

Asking the Question

Listen carefully to any client in crisis for warning signs and risk factors. If you identify any warning sign or many
risk factors for suicide, you should complete a suicide risk assessment. We will discuss risk assessment in more
detail in the next section. 

The first part of the risk assessment is asking about suicide directly. It is important not to use vague language
(e.g. “Are you thinking about hurting yourself? Are you thinking about doing something?”). Use the word
“suicide” or “killing yourself.” Remember, it never hurts to ask. It’s also important that you don’t phrase it in a
way that implies the answer should be no (e.g. “And you’re not considering suicide, are you?”).

Here are some examples:

“When someone is in an unbearable amount of pain like you are describing, sometimes people think about
suicide. Have you had thoughts about killing yourself?”

“When you say that you ‘can’t live like this anymore,’ I’m wondering…are you thinking about suicide?” 

“I’m concerned that you say that you feel trapped and like you don’t have any options. Sometimes when people
feel that way, they may have suicidal thoughts. Are you thinking about killing yourself?”

You should not stop at asking one time. The National Suicide Lifeline recommends asking three questions to
determine whether further assessment is warranted. 

1) Are you thinking about suicide?

2) Have you thought about killing yourself in the past 2 months?

3) Have you ever attempted suicide?

If someone says yes to any of these three questions you should explore further. 

Precipitating Event

There may not always be a clear precipitating event when someone is contemplating suicide. Nothing specific
happened to suddenly make the person want to die. Rather, the person has been experiencing chronic psychological
pain that has become unbearable. This is o�en wrapped up in the cognitive distortions that are so common in
depression. Someone whose life looks great from the outside may actually be experiencing a great deal of pain.
Identifying a precipitating event can be helpful, but don’t waste a lot of time trying to identify one if it’s not apparent. In
the assignments for this course there will always be a clear precipitating event included in the scenario.

Precipitating Event

The focus feeling in crises involving a threat of violence or suicide is always ambivalence. Instead of discussing a
focus feeling, you will discuss ambivalence with the client. More on ambivalence later in this reading. 

1.6. Suicide Risk Assessment

Suicide risk assessment (SRA) refers to process of determining the level of risk for completing suicide. This is
sometimes called a “suicide lethality assessment.” The SRA helps us to develop an appropriate intervention to
address the person’s crisis. In this section, we will discuss how to assess risk.

A note about standardized scales: There are many scales available for suicide risk measurement. One of the
most commonly used is the Columbia Suicide Severity Rating Scale (C-SSRS). This is a great tool, especially for
new clinicians, to ensure that you assess all areas of risk and to document the encounter. However, research has
shown that standardized scales are still not great at determining whether someone will actually complete
suicide or not; thus, clinical opinion is very important. This is why I do not teach how to use a standardized scale
in this course. You’ll learn about the areas of risk that should be addressed to make decisions in order to help
you strengthen your clinical assessment skills. I do encourage you to explore the C-SSRS website to learn more
about the tool. 

The National Suicide Prevention Lifeline is a national leader in the field of crisis intervention and many clinicians
and programs use their guidelines for risk assessment. NSPL identifies four major principles of suicide
assessment: 

1.

Desire

2.

Capability

3.

Intent

4. Bu�ers/Connectedness (or in other words, protective factors). 

This resource shows these four principles and their subcomponents for assessing suicide risk in a visual format.  Let’s
discuss each component:

Desire

Desire refers to a person’s want or wishes to die and/or complete suicide. This includes:

Direct statements of suicidal ideation like “I want to kill myself” or “I want to die”

Psychological pain

Feelings of helplessness and hopelessness

Perceived burden on others

Feeling trapped

Feeling intolerably alone. 

Capability

Capability refers to a person’s capacity for actually completing suicide. Many capability factors will be similar to
the risk factors list. Let’s explore these further: 

Previous suicide attempts: If a person has attempted suicide before, it puts them at a higher risk for attempting
again and completing. They may have become less scared of attempting because they have done it before–think
of Jill’s disposition in the video you watched earlier. 

Exposure to someone else’s death by suicide: Survivors of suicide are at a higher risk for suicide. They may
identify with the pain of the person who died by suicide and now see suicide as a viable option for them.

History of violence towards self and/or others: This refers to a person’s history of self-harm or non-suicidal self-
injury. This can include hitting, cutting, burning, etc. This also refers to violence toward other people. Has the
person been involved in domestic disputes? Has the person ever been arrested for assault? 

Availability of means: If someone has access to firearms, drugs that could be used to overdose, etc., that
increases their capability. Almost everyone has access to common over the counter medications, sharp objects,
tall buildings, a car that could be crashed, etc., so only include those if the client has identified one of them as an

The Lighthouse Project

https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Suicide-Risk-Assessment-Standards-1

intended method. Firearms should be considered even if the client hasn’t identified an intended method because
they are the most common method of completing suicide. Social workers should be knowledgeable about which
medications are likely to result in a fatal overdose. For example, fatal overdose of SSRI (the most commonly
prescribed class of antidepressants) is rare, but an overdose of acetaminophen (Tylenol) is usually deadly. 

Currently intoxicated: If a person is under the influence of alcohol or other drugs, their inhibitions dissolve and
their judgment is impaired. Being intoxicated puts a person at a higher risk of completing suicide at the time of
their attempt. 

Substance abuse: This is a key risk factor for suicide. This may a�ect their social support and other resources
available to bu�er their risk. 

Acute symptoms of mental illness: If a person is having active hallucinations, delusions, or panic, this increases
their capability of completing suicide. 

Extreme agitation or rage: increased anxiety, manic behavior, risky behavior such as reckless driving or
promiscuity, impulsivity, psychomotor agitation such as pacing or wringing of hands, etc., all indicate a
possibility that the client is experiencing a depressive mixed state, in which a person is depressed but also has
symptoms of mania. Research has shown that these states o�en precede suicide attempts.

Sleep deprivation can also contribute to capability because this a�ects judgment.  

Intent

Intent refers to the degree to which a person is motivated by wanting to kill themselves, rather than other factors
(e.g., wanting to stop pain, etc.). The following indicates that intent is present: 

Attempt in progress. For example, if the client is holding a gun in their hand when they call you, or has cut
themselves deeply and is debating whether to proceed further. 

Has a plan to kill self (the more specific the plan, the higher the risk) with a time and method

Preparatory behaviors (e.g., making a will, putting papers in order, boarding dog, etc.) 

Has verbally expressed an intent to die (“I am going to take the pills to kill myself”, “I want to die”)

Bu�ers/Connectedness

Bu�ers are protective factors. These factors bu�er against intent, capability, and desire and can reduce risk. Here
are some important  bu�ers:

Immediate supports: This means that a person is not alone. They have people they talk to on a regular basis.
They live with other people. They have access to the healthcare needed to address their crisis.

Social supports: This means that the person has friends and family members who care about their well-being.
These are people who would be willing to step in to help keep the person safe.

Planning for the future: Sometimes, people who have very specific suicide plans still talk about future plans.
Some examples: wanting to find a spouse; working hard to make a good grade on a paper; talking about a future
vacation or graduation

Engagement with the helper: If a person connects with their social worker or other helpers when they are in
crisis, this can protect against their risk. If they are engaged and cooperative, this is a good sign that they will be
willing to engage in safety planning and follow through. 

Acknowledging ambivalence: This is discussed in detail earlier in the next section of this Guided Reading. This is
when a client acknowledges that a part of them wants to live.

Core values/beliefs: O�en this can involve religious views that suicide is not acceptable, but this also could be
cultural beliefs like “completing suicide is weak,” or “completing suicide is selfish.” 

Sense of purpose: This means that a person has something they want to accomplish in their life. 

Putting it All Together 

Considering desire, capability, intent, and bu�ers helps us to make a clinical decision about risk level. Risk
assessment should consider individual characteristics; however, there are some common “formulas” to estimate
risk. 

Desire alone= Low Risk

Desire + Capability= Moderate Risk

Desire + Capability + Intent= High Risk

Desire + Capability + Bu�ers= Low-Moderate Risk

Desire + Capability + Intent + numerous Bu�ers = Moderate-High Risk 

When determining risk, especially as a student or new social worker, it is important to get supervision or
consultation to help you when you are unsure. It is a good practice to talk to your supervisor or another social
worker anytime you do a risk assessment to get feedback, if possible. It also is important to document this
supervision/consultation for legal purposes. 

Risk level informs appropriate and e�ective intervention. We will discuss intervention options later in this Guided
Reading. 

1.7. Suicidal Ambivalence

Goals of Suicide Assessment

There are two primary goals of suicide assessment: 

1) To determine a person’s level of risk (which you learned about in the previous section)

2) To identify suicidal ambivalence–this is a key part of intervention!

In this section, we will discuss this latter goal. When listening to someone talk about suicidal thoughts and plans, you should
be paying attention to their living and dying clues. This will help you to construct an ambivalence statement that will lead to
planning for suicide intervention.

Suicidal Ambivalence

All people in crisis who share that they are thinking of suicide have some level of ambivalence. This means that a
part of them wants to die and at the same time a part of them also wants to live. If they didn’t, they would not be
talking about it. This video explores the concept in more depth. I don’t recommend getting into a discussion of
ego states with a client who is in crisis, but this can help you have deeper insight as a clinician:

A useful skill in suicide intervention is to listen closely for living clues and dying clues. Put simply, these are
pieces of information you identify while listening to the client that help you understand their reasons for wanting
to die as well as their reasons for wanting to live.

Dying clues are o�en easy to spot–the client may tell you they perceive themselves as a burden, they think
everyone will be better o� without them, they believe that dying is the only way to end their pain, etc.

Living clues can take a little more detective work. Listen closely to understand what your client may not be
able to verbalize directly. Let’s look at three sources of living clues—verbal, situational, and behavioral.

Verbal clues consist of what the client says, both directly and indirectly. This is your primary source of clues.
Clients who are contemplating suicide will o�en make contradictory statements that indicate ambivalence. For
example:

Early in the session a woman states flatly that “nobody cares” and later mentions how important her grandchildren
are to her

A man sighs in despair that he has no friends and later verbalizes guilt because his fishing buddy will feel responsible
because he had no awareness of the client’s depression. 
A mother of young children says that her children would be better o� without her, and also says that she would not
want them to grow up without her
A teen says he has no hope for the future, and later mentions that he is looking forward to moving away for college
(future planning)

Such statements abound and there is a reality in both sides of each statement. Because of the isolation created
by suicidal depression and the resultant cognitive distortions, it becomes extremely di�icult for people to
remember their reasons for living.

More subtle than direct statements, and no less important,  phrases like “I guess so,” “maybe,” or “I just don’t
know” can be “tuned into” and expanded to reveal more concrete conflicts. Utilize the skills you learned last
week to dig into what exactly the client means.

Intense feelings of anger, hate, and guilt o�en lie just beneath the surface of suicidal depression. A sensitive
counselor brings these feelings into the open to be examined. These underlying feelings are o�en the source of
pain that has made suicide seem like a reasonable option.

Ask the client about their religious/spiritual beliefs. Religious beliefs against suicide are an ambivalence factor
for many clients. However, do not assume that just because a client is religious that they believe suicide is
wrong. People have di�erent beliefs even within the same faith community, so always ask directly. For example:
“You’ve mentioned that your faith is very important to you. I’m wondering, what are your religious beliefs about
suicide?”

Situational clues, if and when they are discovered, o�en speak to both the person’s motivation for suicide and
his or her desire for intervention. 

Here are some examples:

A woman takes a lethal dosage of sleeping pills exactly 30 minutes before her husband is due home from work,
knowing that he may arrive home before the pills can take maximum e�ect. 
A person turns on the gas in the kitchen, yet leaves the window over the sink open. 
A man runs a hose from his exhaust pipe into his car to die of carbon monoxide poisoning, yet he does so parked on
the side of a gas station on a fairly busy street near several apartment complexes. 

In each case, the client created a situation where intervention was a strong possibility, but not guaranteed. 

Behavioral clues are particularly apparent in cases of completed suicide, which tells us that we want to be
sensitive to them in crisis counseling. 

A woman completed suicide in a local motel, and before she did so she called five people in town to tell them what
she was planning. By the time the motel manager and one of the people she had called arrived to investigate, it was
too late. 
In addition to the phone calls, she had demanded a ground floor room and had le� the drapes and door open, so it
seems like a part of her wanted to live. But she also wanted to die and in that she was successful. 

In most cases where a social worker is providing suicide intervention, an automatic living clue is that the person showed
up to a session or called their therapist to announce their intentions. If you can’t identify any other living clues, you
can always fall back on this. 

Look for other clues. The person who has a gun and has yet to load it, the person who has a lethal dose of Valium
available and who has not taken any, and the person who plans to shoot himself a�er he gets home from work
are all making strong statements about the tug-of-war going on inside of them which can be explored with
patience and empathy. 

In crises involving suicidal ideation, suicidal ambivalence is the focus feeling. The
discussion about ambivalence replaces the discussion of a focus feeling that you
would have in a typical crisis intervention session.

Suicide, as a crisis, is time-limited. Ambivalence cannot be maintained for very long.
The client will either choose to live or choose to die. You will guide the client to
recognize their ambivalence and invite them to make a choice to live, even if only for
a specific length of time. Called a To Live Decision, the very act of verbalizing a will
to live demonstrates to the person that he or she is in control of his or own life and
that he or she can further decisions that will free him or her from the trap of
ambivalence. It is a decision made by the client and facilitated by the counselor. This
is the heart of suicide intervention.

Here is an example. Watch the video below, then read the assessment of the person’s living and dying clues. 

Jill was at high risk for completing suicide because she has attempted before and has a plan; however, her
ambivalence is evident in this interview. Let’s identify some of her living and dying clues:

Her living clues included:

• Telling her therapist (knowing that he would have an obligation to stop her)

• “part of me doesn’t want to die”

• “I want to talk about it”

• family

Her dying clues included:

• “I found the solution” 

• Has a plan with means and time frame

• Putting a�airs in order

• Thinks this is the only solution for solving stress and pain

From here, we can construct an ambivalence statement to help the client acknowledge that there is a part of
them that wants to live. Here is a sample template:

“I’m hearing that you are in a lot of pain right now, and  (dying clue), (dying clue), (dying clue). I also hear you say
that (living clue), (living clue), (living clue). It seems that there is a part of you that wants to live and a part of you
that wants to die. Would you agree with this assessment?” 

It’s important to acknowledge dying clues first. If the client
doesn’t feel that you have truly heard and understand the part
of them that wants to die, they will not be willing to
acknowledge the part of them that wants to live. Be careful to
avoid being a “cheerleader for life.” Meet the client where they
are.
Here is a sample ambivalence statement:

Counselor: I’ve heard you say that you are really struggling right now and are feeling hopeless that things will get
better.  You lost your job and you got a DUI and you don’t know how you are getting to pull things back together.
That is the part of you that wants to die. I also hear you say that you want to be there to watch your children
grow up. You also have said that you think that this would have a great impact on your husband and that you are
scared of dying. Those are the parts of you that want to live. Do you agree that there is a part of you that wants to
die and a part of you that wants to live?

Client:  Yeah…I guess that makes sense.

Counselor: Okay, I’m glad you are able to see that. I want us to focus on that part of you that wants to live to keep
it safe. 

Sometimes a client will not immediately acknowledge ambivalence. You should make sure that you are
reflecting feelings and giving an accurate summary. Ask for clarification. They may not have had enough time to
fully express how they are feeling. They need more space to talk about why they want to die. 

If the client still does not acknowledge ambivalence, this means that they are at a very high-risk level for
completing suicide. When a person cannot agree to this and keeping the part of them that wants to live safe, this
generally triggers a need to break confidentiality to get someone into immediate treatment. 

When the person does acknowledge ambivalence, you should then shi� the focus of the conversation to their
living clues and safety planning. A good transition may be to say “I’m glad to hear that you can acknowledge that
there is a part of you that wants to live, and I want to help you keep that part of you safe. Let’s come up with a
plan for you to take care of yourself and stay safe.” 

One more tip: Avoid using guilt or shame as the primary reason to live. Most people contemplating suicide are
already feeling guilty and ashamed. Gently pointing out that other people would be hurt or disappointed by
their death can be helpful, but don’t rely on it too heavily. They need a reason to live for themselves. There is
meaning in choosing to live because you want to, rather than because you don’t want to hurt or disappoint other
people.

1.8. Suicide Intervention

Risk informs intervention
As mentioned before, intervention should be based on the level of risk you assessed. Your assessment and planning
should be unique to each client. However, some guidelines are helpful. The chart below indicates appropriate
intervention based on risk level. This chart is adapted from Kanel (2019)’s A Guide to Crisis Intervention.

Factor Client
Response

Level Intervention

Ideation No Low • Supportive crisis intervention, focus on
self-care

• Provide number to National Suicide
Prevention Lifeline (1-800-273-TALK or
8255) and encourage them to call if they do
have thoughts of suicide or are in crisis
when you’re unavailable

Yes (Go to next factor)

Plan No Low • Supportive crisis intervention, focus on
self-care

• Verbal no-suicide agreement with time
frame

• Provide National Suicide Prevention
Lifeline (1-800-273-8255) and encourage
them to call if their ideation escalates

Yes (Go to next factor)

Means No Low-
Moderate

All of the above plus:

• Maintain regular contact/follow-ups

Yes Moderate All of the above plus:

• Notify family or other social supports of
suicidal ideation

• Facilitate means removal

• Referral for outpatient medication
evaluation

Can
anything
stop you
now?

Yes Moderate All of the above plus:

• Focus on reasons to live, guide client to
make a to-live commitment and plan for
safety and self-care

No High • Hospitalization

Let’s talk about these di�erent options in more detail:

Supportive crisis intervention: This means that you follow the ABC model as you would with any other crisis. Pay
extra attention to exploring functioning and including self-care in the plan of action. Clients contemplating
suicide have o�en had a significant decrease in functioning. For someone who is very depressed and/or in crisis,
planning out what they will do over the next week or more can be overwhelming. They can also be paralyzed by
indecision. For these reasons, clients in crisis o�en benefit from having a very specific plan that focuses on the
next 24-48 hours.

National Suicide Prevention Lifeline: The National Suicide Prevention Lifeline  (1-800-273-TALK or 8255) is a
national network of local crisis centers that provide 24/7, free and confidential telephone support for people in
crisis. I provide this number to anybody who I assess to be moderately to severely depressed, even if they deny
thoughts of suicide. It is an excellent resource.

Regular contact and follow-up: If someone is at a moderate risk level or higher, it is a good idea to incorporate
check-in calls or more frequent visits until a person’s crisis has fully resolved. This helps a person stay
accountable and to have help if thoughts arise again. 

Verbal no-suicide agreement: Written contracts have been found to be largely ine�ective and can even harm the
therapeutic relationship. However, having a person say out loud that they are making a decision to stay alive and
not complete suicide can be helpful. You should specify the time frame of the commitment. Maybe your client
isn’t willing to say they won’t attempt suicide someday in the future, but they feel capable of making that
commitment until their next session. The higher their risk, the shorter the commitment and time to follow-up
should be. So for a client who is moderate-high risk, maybe the commitment could be until your follow-up
phone call tomorrow or the next day. For someone who is low-moderate risk, the commitment can be until their
session next week. You should prompt the client to renew this commitment at each session until they are no
longer having suicidal ideation.

This agreement may include a plan for if the person has thoughts that arise. For example: “I will not act on any
thoughts or plans about suicide before seeing you at our session next week.” or “If I have the urge to act on my
thoughts, I will call the crisis hotline before taking any actions.” or “If I have the urge to act on my thoughts, I will
go to the nearest ER.”  

Involving family or other social supports: It is important to ask if the person has told anyone in their life about
their suicidal thoughts. If they have not, encouraging the person to tell a trusted person can be part of an action
plan for safety. For someone at a high risk level, you may ask to call a family member together to help remove
access to means and provide immediate support. You also could have the suicidal person stay at a trusted
person’s house until the crisis has resolved. 

Removal of means: This means having the person get rid of (or make inaccessible) the means they have planned
on using for suicide. For example, you may have someone flush pills down the toilet or give a firearm to a friend
or family member. Having access to firearms is a significant risk factor for completing suicide. Even if they don’t
have a plan now, they could make an impulsive decision and would have a high lethality method available.
Removing firearms and other weapons from the home is recommended for people struggling with depression
and other mental health issues. 

Inpatient psychiatric treatment/ hospitalization: If a person is high risk and is unable/unwilling to acknowledge
ambivalence and make a plan for safety and self-care then hospitalization may be needed even if it is against the
client’s wishes. In my opinion, hospitalization should be a last resort. The admission process–being evaluated
in the ER, waiting for a bed, possibly being transferred to a facility far away–can all be very traumatic and
dehumanizing. Patients will be evaluated and started on new medications, but usually not kept in the hospital
long enough for most antidepressants to begin taking e�ect. If someone truly cannot be maintained safely in the
community then the hospital is a good option to keep them safe for a few days while they stabilize. If they can
make a suitable plan for safety at home or with natural supports then they should remain in the community. The
goal of this course is to help you develop the skills needed to help clients do this. 

Imagine that you are very depressed and you are in so much pain that a part of you doesn’t want to live
anymore. You gather the courage to tell a social worker, and they immediately send you to the ER to be
evaluated. Your world is flipped upside down and everybody in your life finds out about it. A�er a few days, you
are discharged with a list of medications that haven’t kicked in yet. A few weeks later you receive a large bill for
your ER visit, ambulance transport, and inpatient care at a separate facility.

Now, imagine that the social worker takes the time to really listen, to hear and understand the part of you that
wants to die and they help you recognize the part of you that wants to live. They invite you to recognize that
ambivalence and o�er to help you make a plan to take care of that part of yourself. Together you make a plan
that includes getting yourself something to eat and taking a shower, telling a trusted social support about how
you’ve been feeling, removal of means, and a follow-up call from the social worker in 48 hours. You make a
commitment out loud to yourself that you will not do anything to hurt yourself before that phone call. If you are
having increased thoughts of suicide, you will call the 24hr hotline that your social worker provided you. When
your social worker calls you to follow up two days later, you are feeling much better. You make a plan for
continued self-care and follow-up.

In the first scenario, the client learns that disclosing suicidal ideation triggers a series of very disruptive events.
In the second scenario, the client learns that it is okay to be honest about your suicidal ideations because this
person can help you. Which client do you think would be more likely to tell someone if they feel this way again in
the future?

That said, if a client is not able/willing to acknowledge ambivalence and make a plan, or if they disclose suicidal
ideation but are not willing to answer enough questions for me to assess their risk, then that is a red flag for me
that hospitalization may be warranted. Also, if you think someone is being manipulative, err on the side of
hospitalization–that liability is not a risk I’m willing to take with someone who is not being honest with me. 

Still questioning my assertion that hospitalization should be a last resort? Consider this from Marsha Linehan:

As Marsha said, there is an institutional belief that hospitalization is the necessary and appropriate response
anytime a client is contemplating suicide. In your field placements and in your first few years out of school, you
may get some pushback from other professionals if you try to help your clients avoid hospitalization. There’s not
much you can do about this when you’re a new social worker–you have to defer to your supervisor, especially if
you are practicing under their license. But I hope that as you gain experience and authority you will recall some
of what you’ve learned in this course and, together, we can gradually change the standard response to
addressing suicidal risk. 

A note about documentation and liability
Always ask yourself: “if this client completed suicide tomorrow and a neutral third party reviewed my
documentation, would I be able to stand by my assessment and intervention?” If you didn’t document it, it
didn’t happen, so if you talked with a client about removing access to means, for example, be sure to document
that (and especially document if you suggested it and they refused!). If they agreed to a verbal no-suicide
agreement, document that. If you asked them if they were considering suicide and they said no, document that. 

In the early days of managed care, many therapists were trained to document as little as possible to protect their
clients’ privacy. That advice is outdated. It’s important to document thoroughly to demonstrate competence, to
mitigate risk, and to facilitate e�ective follow-up (you may have another clinician following up behind you or you
may simply need a reminder for yourself of what was discussed).

Safety contracts vs safety plans: While written no-suicide contracts are o�en ine�ective, written safety plans
may be helpful. This is a document that helps a person identify they are entering a crisis and what supports they
can use to help them. Having a visual reminder when in crisis is helpful because judgment is o�en impaired due
to intense emotion. You can find a simple template here. I don’t focus on them in this course because students
tend to rely on them as a crutch (for example, just putting “written safety plan” on the client’s plan of action
instead of outlining the specific steps the client will take for safety and self-care). That said, I recommend saving
the document linked above because it could be a useful tool in your real-life practice with clients.

https://www.genhs.org/News/Quality-Matters/Article/129/the-top-10-reasons-against-the-use-of-no-suicide-contracts

https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Brown_StanleySafetyPlanTemplate

1.9. Hospitalization

As I mentioned on the previous page, hospitalization should be a last resort. That said, if a person is high risk and is
unable/unwilling to acknowledge ambivalence and make a plan for safety and self-care then hospitalization may be unavoidable. There are

several ways to facilitate hospitalization and this varies based on state and local laws and resources. These are some of the most common

processes: 

Direct admit–this is probably the least traumatic option for the client. Call a local psychiatric hospital during business hours and ask whether they

have a bed available. They can briefly screen the client over the phone, present the case to the doctor, and let you know within an hour or two

whether they will be able to admit. Many facilities o�er transportation and can go pick the client up from their home the same day.

Call 911–this may be the best option if the client is not willing/able to go to the hospital voluntarily, if they have already begun an attempt, if the

client is physically assaulting someone or threatening them with a weapon, etc. If you are talking with the client on the phone, it may be best to

have a colleague call 911 while you stay on the line with the client. If the client is calm enough, have them unlock their door, secure any animals,

and gather up their medications to bring with them. If they have taken any medications in an attempt to overdose they should put the pill bottle in

their pocket so it will be easy for first responders to see what they’ve taken. Stay with the client or on the line until first responders arrive.

ER–this is one of the most common ways in which people enter the mental health system, and also one of the most traumatic. Most ERs are not

designed to care for people experiencing a mental health crisis. Even in ERs that do have an area dedicated to psychiatric care, patients may wait

for hours in a room with other patients in crisis before being transferred to an inpatient unit/facility. They are usually sent to the first facility that

accepts them, even if it’s far away. In Louisiana, it is not uncommon for patients to be hospitalized hours away from home because that was the first

place that responded to the request for a bed.

Mobile crisis team–some communities have a mobile crisis team, usually comprised of masters-level clinicians and/or trained paraprofessionals.

They can assess the client at home (or wherever they are located) and help connect them with resources for treatment. Their goal is usually to

avoid involving law enforcement and to prevent hospitalization, but they can facilitate hospitalization if needed.

Crisis center–similar to the mobile crisis team, some communities have a center dedicated to crisis care. They may work in conjunction with the

mobile crisis team. Clients can o�en “walk-in” to these facilities, similar to an ER. The sta� there can evaluate them and help connect them with the

appropriate level of care.

1.10. Observe a Suicide Intervention Role Play

Let’s review what you’ve learned by watching some role play videos. Chiera and Sarah are students from a prior
module who graciously agreed to play the role of the client while I acted as the counselor. I have also uploaded a
completed Crisis Contact Note and Suicide Risk Assessment and Intervention Form below each video.

Chiera Crisis Contact Note

Chiera Suicide Risk Assessment and Intervention Form

Sarah Crisis Contact Note

Sarah Suicide Risk Assessment and Intervention Form

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60282/Chiera%20Crisis%20Contact%20Note

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60282/Chiera%20suicide%20risk%20assessment%20and%20intervention%20form

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60282/Sarah%20Crisis%20Contact%20Note

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60282/Sarah%20suicide%20risk%20assessment%20and%20intervention%20form

What are your thoughts a�er watching the videos? Do you agree with my risk assessment for each of these
clients? Was the plan of action for each client thorough and appropriate? What did you think of the conversation
about ambivalence? In my opinion, guiding the client to acknowledge ambivalence and make a decision to live is
the most important part of suicide intervention.

I actually did not feel like I was at my best that day–that happens to all of us sometimes and is part of why self-
care is so important for social workers, which we will learn more about later in this reading. I was frazzled that
morning and didn’t take enough time to get myself into “counselor mode” before we got started. I also gave
them the wrong number for the crisis hotline–I told them that 800-273-TALK was 4255, but it’s 8255. Hopefully,
they could figure it out by dialing TALK if they really needed it.

1.11. How Social Supports Can Help

In your social work practice or your personal life, you may have people who are not mental health professionals
come to you and ask how they can support a loved one who is at risk of suicide and respond to warning signs. 

I usually have two main points to convey in these conversations:

Addressing some of the myths and misconceptions about suicide, such as the idea that talking about it will
encourage it, or “put the idea in their head,” or that people who disclose suicidal ideation are “doing it for attention.”
The best response I’ve ever heard to that statement is, “Well they’ve got my attention.” There is no harm in asking and
talking about it is key to prevention. 
Coaching them to understand the concept of suicidal ambivalence. I encourage the person who’s asking me for
advice to really listen and understand their loved one’s reasons for wanting to die and reasons for wanting to live and
help that person recognize their ambivalence. Understanding ambivalence also helps bust some myths, such as the
idea that if you really wanted to kill yourself you wouldn’t tell anybody, or that if you have people who love you or
other positive factors in your life you shouldn’t want to die. Think of some famous people who have died by suicide in
recent years–Robin Williams, Kate Spade, Anthony Bourdain–each of them seemingly had a lot to live for, but in
private were su�ering a lot of psychological pain. Truly understanding this pain is the only way to help them.

For people who are interested in receiving formal training, there are several training programs o�ered by
LivingWorks that are aimed at non-clinicians. LivingWorks Start is a one hour online training, SafeTalk is a half-
day in-person training, and Applied Suicide Intervention Skills Training (ASIST) is a two-day face-to-face
workshop. You can learn more about the LivingWorks trainings and how they work together to create safe communities here. These
trainings are particularly valuable for professionals in the community (teachers, first responders, healthcare workers, etc.). Imagine if most

people had some basic idea of how to help someone contemplating suicide, just as most of us who have worked in the helping professions

have been trained in CPR at some point? I haven’t been CPR-certified in years, but I remember enough that I could at least give it my best

shot until professionals arrive. It would be wonderful if we had that same level of community awareness around suicide prevention. 

https://www.livingworks.net/infographic

2. Violence

This second chapter will focus on violence assessment and intervention. The process of violence assessment
and intervention is very similar to what you have learned in the previous chapter about suicide assessment and
intervention; thus, this chapter on violence is much shorter and o�en refers to suicide assessment and
intervention. 

We also will cover workplace violence. You will learn about standards for social worker safety which will help
you to assess your risk for being a victim of violence in your professional practice and to apply strategies to
mitigate this risk. This chapter also examines how organizations and individual social workers can promote
workplace self-care and safety. This content on workplace safety highlights key concepts from James &
Gilliland’s (2018) Ch. 14 and provides some additional resources. 

2.1. Scope

Violent crime is actually declining in the United States; however, public perceptions o�en overestimate the
actual rates. For more information about trends in crime, check out this brief article. 

A trustworthy source of statistics on violent crime is the FBI’s Uniform Crime Reporting (UCR) Program. In 2018
(the most recent year for which full data is available) an estimated 1,206,836 violent crimes occurred nationwide,
a decrease of 3.3 percent from the 2017 estimate.

Here’s a breakdown of violent crime in 2018 by type:

Aggravated assault: 66.9%
Robbery: 23.4%
Rape: 8.4%
Murder: 1.3%

This article o�ers some thoughtful insights regarding violence and mental illness. Some key takeaways:
96% of violent crimes are committed by people without mental illness
Around 10% of people with schizophrenia or other psychotic disorders behave violently.
The prevalence of violence among patients in psychiatric settings varies depending on the setting

2.3-13% in outpatient settings
10-36% in acute care settings
20-44% among involuntarily committed patients

From this we can deduce that while violence is not common among people with mental illness, social workers and
other helpers are likely to come into contact with those who are violent while working in mental health settings. 

https://www.pewresearch.org/fact-tank/2019/01/03/5-facts-about-crime-in-the-u-s/

https://www.fbi.gov/services/cjis/ucr

https://ucr.fbi.gov/crime-in-the-u.s/2018/crime-in-the-u.s.-2018/topic-pages/violent-crime

https://jech.bmj.com/content/70/3/223

2.2. Risk Factors

As a social worker, it is important to understand the factors that predispose someone to be violent. The most
salient risk factor for violence is a history of violence. Many of the risk factors for violence are also risk factors
for suicide. 

You can find an additional resource explaining the risk factors for violence, especially as they relate to workplace
violence for mental health professionals, here. 

Risk factors for violence:

•Age:  males 15-30 & older adults

•Substance use:  including drugs, alcohol, and tobacco. These are especially concerning when comorbidities
with mental health issues are present

•Access to firearms: access to firearms – whether legal or illegal – is one of the main drivers of gun violence.

•History of violent behavior:  serious violence or homicide, sexual attacks, assault or threat of assault with a
deadly weapon, being hospitalized or incarcerated for violent behavior

•History of violent victimization or exposure to violence: PTSD is associated with an increased risk of violent
behavior, though most people with PTSD are not violent

•Psychological disturbances: small percentage are violent, but mental health workers come into contact with
them o�en

•Social stressors: loss of a job, job stress, break up of a relationship

•Family history: social isolation, lack of family support, cruelty to animals, witnessing family violence, enduring
excessive physical punishment, abandonment, deprivation, neglect

•Developmental factors: low IQ, social or cognitive deficits, ADD/ADHD, learning disorders, poor academic
performance, poor behavioral control

•Work history: job loss and economic instability, a belief that they have been wronged by an employer

•Time:  Fridays and Saturdays during “party hours”, sundowning for older adults

•Presence of interactive participants: other sta�, family members, police o�icer

•Motoric cues: these are clues that may indicate an immediate threat of violence– tense muscles; darting eye
movements; staring or completely avoiding eye contact; closed, defensive stance; twitching muscles, fingers,
eyelids; body tremors; disheveled appearance; pacing back and forth

Assessing Violence

2.3. Violence Assessment & Intervention

Violence assessment and intervention is parallel to suicide assessment and
intervention. In this course we will use the same process for addressing violent risk
as we do for suicide.

There are a few key points about violence assessment and intervention: 

A person is considered high risk for violence when they have a specific plan (time, method, intended victim) and are
unwilling or unable to acknowledge ambivalence about committing the violent act. Social workers must use their
clinical judgment to balance concerns for client confidentiality and public safety. When someone is at high risk for
committing an act of violence, many states require mental health professionals to notify law enforcement and/or the
intended victim (even if the client agrees to a safety plan). You can learn more about these mandates in Chapter 3 of
this Guided Reading. 
When working with a potentially violent person, it is important to maintain a calm demeanor. Avoid sudden
movements. Do not challenge or confront the person, and ignore any insults they may make to you.
If possible, position yourself between your client and the nearest exit so that you can make an emergency escape if
needed. Avoid being trapped. 
Use the active listening skills you learned in Week 2 of this course to build rapport. Work to understand the client’s
perspective and communicate to them that they are being heard. Allowing the client to air their grievances without
judgement is o�en enough to defuse the situation. 
When asking about a plan for violence, it is important to also ask if the person has plans to kill themselves. Many
homicides are murder-suicides. 
As in all crisis intervention, clients will be more likely to follow through on a plan that they created themselves.
Encourage the client to take an active part in deciding what they will do to resolve the crisis. 
Standardized measures are o�en very accurate at predicting whether a person will be violent. However, they are not
very clinically useful because: 1) there is not enough time to complete it before the person may act, and 2) most
require the client to self-report and they are o�en not in a state of mind to sit and complete a questionnaire. For this
reason, we will focus on teaching you skills for using your clinical judgement to assess risk. 

In Week 3, we are focused on clients’ violent and homicidal ideation. We will cover crises related to victims of violent
acts later in the course. 

3. Legal and Ethical Considerations for Crises of Lethality

Suicide and violence are two crises that can lead to a need to breach client confidentiality due to the risk of
imminent harm. There are both legal and ethical mandates surrounding imminent harm. Ethical standards can
vary by profession- for social work, we adhere to the NASW Code of Ethics. Laws vary by state on these issues,
and Health Insurance Portability and Accountability Act (HIPPA) also provides additional regulations regarding
confidentiality.  Social workers must also consider the agency policies of their employer when making these
ethical decisions. 

Ethical Standards

The NASW Code of Ethics provides guidance on decision-making surrounding confidentiality and safety,
primarily in Standard 1 Social Worker’s Ethical Responsibilities to Clients. Let’s look at the language the Code
uses. Information related to these issues is highlighted.

1.01 Commitment to Clients 

“Social workers’ primary responsibility is to promote the well-being of clients. In general, clients’ interests are
primary. However, social workers’ responsibility to the larger society or specific legal obligations may on limited
occasions supersede the loyalty owed clients, and clients should be so advised. (Examples include when a social
worker is required by law to report that a client has abused a child or has threatened to harm self or others.)” 

1.02 Self-Determination 

“Social workers respect and promote the right of clients to self-determination and assist clients in their e�orts to
identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social
workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent
risk to themselves or others.”

1.03 Informed Consent

“Social workers should obtain client consent before conducting an electronic search on the client. Exceptions
may arise when the search is for purposes of protecting the client or other people from serious, foreseeable, and
imminent harm, or for other compelling professional reasons.”

1.07 Privacy and Confidentiality

“Social workers should protect the confidentiality of all information obtained in the course of professional
service, except for compelling professional reasons. The general expectation that social workers will keep
information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and
imminent harm to a client or others. In all instances, social workers should disclose the least amount of
confidential information necessary to achieve the desired purpose; only information that is directly relevant to
the purpose for which the disclosure is made should be revealed.”

What does this mean?

Social workers are allowed to break general expectations of confidentiality and privacy “to prevent serious,
foreseeable, and imminent harm to a client or others.” This includes doing an electronic search (e.g., Google,
social media, etc.) for your client. In the case of suicide and homicide, this means social workers are able to tell
authorities or family members that a client is at risk for harming themselves or others to ensure the safety of all.
In the case of homicide threats, this means social workers are able to notify identified victims and law
enforcement. Social workers also can help facilitate involuntary hospitalizations in these cases. 

The Code only o�ers guidelines, not clear rules, which means clinical judgment must be used to determine
whether a client’s situation meets the criteria to break confidentiality. The Code also does not state that social
workers have a “duty to warn” or obligation to break confidentiality but only permits them to do so. Social
workers must document breaches of confidentiality thoroughly to assert that this action was necessary.

https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Consultation or supervision should always be utilized before making these decisions. You should not be the only
person who knows that this is happening. The Code also encourages social workers to explain the limits of
confidentiality at the start of the therapeutic relationship and to continue to remind them of limits. 

HIPPA

In this FAQ, the U.S. Department of Health and Human Services clarifies that HIPPA does not prevent mental
health professionals to disclose Privileged Health Information (PHI) without a client’s permission in situations of
imminent harm. 

State Laws

Involuntary Hospitalizations  

Louisiana RS 28:53 sets regulations for Physician’s Emergency Certificates for involuntary hospitalizations. In
Louisiana, this can only be done by a physician (or nurse practitioner or physician’s assistant under supervision
from a physician); however, in some states, a social worker can approve these. Oddly enough, in Louisiana, this
is handled by the coroner’s o�ice. In other states, this is generally handled by other state departments. This does
not mandate social workers to report if their client is a threat to themselves or others.

“Duty to Warn”

Due to the Taraso� vs. California Board of Regents case, many states have implemented laws mandating mental
health professionals to notify intended victims and law enforcement when a client makes a serious and credible
threat of violence. These two articles discuss this issue as it relates to social workers and each specific state. 

Mental Health Professionals’ Duty to Warn State Laws- This article provides more information about the Taraso�
case and a detailed database of “duty to warn” laws for all states. Take a look to check out the laws in your state. 

Social Workers and the “Duty to Warn”- This article discusses how “duty to warn” laws fit within social work
ethics. 

As a general rule, if you assess a client to be at high risk of violence you have a duty to warn, even if the client
acknowledges ambivalence and commits to a safety plan. 

State Practice Acts and Confidentiality 

Every state has a “practice act” that regulates the practice of social work. These laws allow for breaches of
confidentiality to report threats of violence or suicide. The purpose of these laws (and regulatory boards created
by these laws) is to protect the general public, not social workers. The purpose of NASW is to lobby and advocate
for the social work profession. 

Louisiana’s Social Work Practice Act states:

“No social worker may disclose any information he may have acquired from persons consulting him in his
professional capacity that was necessary to enable him to render services to those persons except…..when a
communication reveals the intended commission of a crime or harmful act and such disclosure is determined to
be necessary by the social worker to protect any individual or person from clear, imminent risk of serious mental
or physical harm or injury, or to forestall a serious threat to public safety.” 

It is important for you to know the law in your state. A good place to find this is through your state’s licensing
board. 

Summary

Social workers are generally protected when breaking confidentiality in order to keep clients and the general
public safe. It is important to document these encounters well to show evidence to support that there was an
imminent risk of harm. It also is a best practice to consult with a supervisor or colleague before deciding to break
confidentiality (and to document the use of this consultation). As mentioned in section 1.8 of this Guided
Reading, always keep liability in mind and remember the importance of documentation. Your documentation
should clearly outline your assessment, intervention, and decision regarding duty to warn.

https://www.hhs.gov/hipaa/for-professionals/faq/3002/what-constitutes-serious-imminent-threat-that-would-permit-health-care-provider-disclose-phi-to-prevent-harm-patient-public-without-patients-authorization-permission/index.html

https://legis.la.gov/Legis/Law.aspx?d=85245

http://www.ncsl.org/research/health/mental-health-professionals-duty-to-warn.aspx

https://www.socialworkers.org/About/Legal/Legal-Issue-of-the-Month/Social-Workers-and-the-Duty-to-Warn

4. Social Worker Safety in the Workplace

Current data shows that mental health professionals are second only to law enforcement professionals for
the highest rate of being a victim of workplace violence! 

As social workers, we o�en find ourselves in situations that may be unsafe. In 2013, NASW recognized this
formally and created Guidelines for Social Work Safety in the Workplace. The U.S. Occupational Safety and
Health Administration (OSHA) also has set guidelines for preventing workplace violence in the health care and
social services sectors. 

REFLECT: Review these guidelines. Does your internship agency have policies that align with these guidelines?
How does your workplaces or internship site meet or not meet these recommendations? In next week’s
assignment you will be asked to share your reflections with your classmates. 

Systemic Factors Contributing to Social Work Workplace Violence

Mandatory Reporting:  Child and elder abuse reporting has led to a negative view of social work and helping
professionals 

Deinstitutionalization has led to problems that lead clients with mental health issues to regress a�er discharge:

Lack of facilities for transients
Shortage of sta�
Lack of follow-up care
Inability to monitor medication compliance 

Risk Factors for Being a Victim of Workplace Violence

Helpers are in denial that a client would hurt them
Helpers do not see the view of the client being in a frustrating,  threatening, frightening situation and unaware that
their behavior may be seen as provocative by the client
Helpers who are burnt out
Helpers who are new to the field 

Secondary Victimization

Workers that are victims of violence in the workplaces o�en experience scrutiny from their agency.
Unfortunately, a prevailing attitude is: “This happened because the worker did not handle the situation
correctly.” 

https://ovc.ncjrs.gov/ncvrw2018/info_flyers/fact_sheets/2018NCVRW_WorkplaceViolence_508_QC

https://www.socialworkers.org/LinkClick.aspx?fileticket=6OEdoMjcNC0%3d&portalid=0

https://www.osha.gov/Publications/osha3148

This leads to additional psychological ramifications in addition to the physical injuries.

4.1. Improving Workplace Safety

The following section summarizes and supplements information from Guidelines for Social Work Safety in the
Workplace. 

How agencies can create a culture of safety
Ensure sta� feel comfortable reporting concerns or requesting assistance without fear of retaliation, blame, or
questioning of their competency
Apply safety precautions universally with all clients and in all settings to avoid stereotyping particular groups of
people. Violence can and does occur in every economic, social, gender, and racial group. 
Establish safety plans as a matter of routine planning. Institute polices and procedures that maximize sta� safety and
security in both the o�ice and the field. Consider forming a Safety Committee to review these policies and procedures
on an ongoing basis. 
Have specific policies in place if workers are asked to perform dangerous tasks, such as removing a child or disabled
adult from a home.
Provide resources and support to sta� who experience or witness violence. This includes assessing the need for
medical care, debriefing, adjusting the worker’s caseload if needed, o�ering counseling through an Employee
Assistance Program, and providing financial compensation for damage to property
Provide sta� with training on de-escalation and intervention techniques at orientation and annually 
Develop and implement an incident reporting system to document and track instances of threats, acts of violence,
and damage to property. Create a mechanism for reporting and collecting data on an ongoing basis
For field workers, maintain a record of scheduled appointments, including addresses and expected length of each
appointment. Maintain contact with workers throughout the day and have a plan in place for notifying law
enforcement if a worker cannot be located. 
Provide infrastructure and technology that facilitates worker safety:

O�ices and other spaces should have multiple exits so that workers can escape violent situations
Arrange spaces so that workers are positioned between the client and the exit
Install alarm systems appropriate to the population served. This may include security cameras, panic buttons in
o�ices and/or worn by workers, mobile safety devices that incorporate GPS for employees in the field, etc.
Provide open meeting spaces where sta� can meet with clients who may become verbally abusive or aggressive.
Restrict access to objects that may be used as weapons (for example, stapler, paper weights, scissors, chairs or
o�ice décor that can be picked up and thrown, etc.)
Provide a secure building entry. Options may include a door that must be unlocked electronically, a security guard,
metal detector, bulletproof glass, etc. Entryways and parking lots should be well-lit. 
Employee’s workspaces should be secure and separate from public spaces
Field workers should be provided with cell phones. Consider establishing code words to help workers convey a
threat discreetly. 

What workers can do to maximize safety
Be aware of what personal information about you is available online. Try Googling yourself. Double check your
privacy settings on social media. Verify that your state social work licensing board does not require you to opt-out of
publishing your address (LABSWE had my home address published in their directory until I opted out!)
Utilize your knowledge of risk factors for violence to inform your assessment of risk with each client.
Avoid appearing timid, vulnerable, lost, or confused, but you should also be careful not to develop a lax attitude
and/or overconfidence. Be careful not to over- or underestimate safety threats due to your own bias or stereotypes.
Be aware of your environment. Always position yourself between the client and the exit, especially if the client has
risk factors for violence. Keep supplies that could be used as weapons (ex: scissors, staplers), out of view
Engage appropriate support when needed. This may include asking a colleague, supervisor, or law enforcement to
accompany you
Consider whether your appearance and/or attire may increase your vulnerability. You may not be able to change some
of these circumstances, but you should be aware that they may increase your risk and use extra caution.

https://www.socialworkers.org/LinkClick.aspx?fileticket=6OEdoMjcNC0%3d&portalid=0

Wearing jewelry and other valuables
High-heeled shoes
Earrings that could be grabbed, necklaces or landyards that could be used to choke you
Political buttons or religious jewelry that may trigger reactions
Visible physical conditions that may increase vulnerability (pregnancy, disabilities, use of cane or walking aid)
Tattoos or body piercings that cannot be covered and that might attract/increase attention

When conducting field visits:
Ensure that you have a complete and accurate address
Assess whether the neighborhood poses a risk for violence. Have any events occurred in the neighborhood within
the last 48 hours that might increase risk (for example, homicides, abductions, robberies, drug raids,)
Consider the time of day–avoid evening visits if other risk factors are present
Keep your cell phone charged and ensure that you have reception
Consider whether agency identification (a logo on the vehicle you’re driving, for example), may put you at risk
Are there groups or individuals in the path to the home or near the location of the visit?
Does accessing the space require the use of an elevator or flights of stairs?
Consider parking on the street instead of in a driveway so you cannot be blocked in.
Who is likely to be in the client’s home during the visit?
Is/are the client, family members, or friends of the client known to engage in criminal or dangerous activities in the
home?
Is the family known to have weapons?
Will the social worker engage in high-risk activities during the visit (for example, removing a child, notifying of
reduction in benefits, terminating parental rights, executing a civil commitment procedure, helping a domestic
violence victim to a safe house, delivering other potentially unwelcome information)?

When transporting clients
Assess the client’s level of agitation (if any), use of intoxicants, and the meaning of the appointment to the client
Assess the possibility that the client has a weapon
Verify that the vehicle is free from potential weapons (for example, pens, pencils, magazines, books, handheld
devices, hot beverages)
If transporting a child:

Have a colleague or supervisor in the vehicle with you
Use an appropriate child safety seat
Engage the child safety locks in the vehicle

4.2. De-Escalation Techniques

The following section summarizes and supplements information from Verbal De-Escalation Techniques for
Defusing or Talking Down an Explosive Situation and Managing Clients Who Present with Anger.

Two important concepts to keep in mind:

You cannot reason with somebody who is very angry. Your objective in de-escalation is to help the person feel more
calm first. Discussion of logic and reason will have to wait.
De-escalation techniques are not a natural instinct, even for people who feel called to the field of social work or think
of themselves as being very good listeners. Human instinct is to fight, flight, or freeze when confronted with a threat.
In de-escalation, we suppress that instinct and instead make a conscious e�ort to appear centered and calm. This
takes practice!

There are two components to de-escalation techniques: verbal and non-verbal

Non-verbal
Appear calm, centered and self-assured even if you don’t feel it. Your goal is to model composure for the client and
create an atmosphere of safety and comfort.
Relax your facial muscles and take slow, deep breaths. Minimize your arm and hand movements.
Never turn your back for any reason. If possible, position yourself between the client and the exit. 
Do not stand full front to person. Stand at an angle so you can sidestep away if needed.
Always be at the same eye level. Encourage the person to be seated, but if he/she needs to stand, you stand up also.
Allow extra physical space between you – about four times your usual distance. 
Do not maintain constant eye contact. Allow the person to break his/her gaze and look away.
Do not point or shake your finger.
DO NOT SMILE. This could look like mockery or anxiety
Do not touch – even if some touching is generally culturally appropriate and usual in your setting. Very angry people
may misinterpret physical contact as hostile or threatening.
Keep your hands visible to the client

Verbal
Use a low, monotonous tone of voice
Do not defend yourself or your colleagues against comments, insults, or misconceptions about their roles. Ignore
these statements. 
Demonstrate respect for the client even when setting limits or calling for help. A client who feels disrespected may
escalate aggressive behavior. 
Use your active listening skills to empathize and reflect. Remember that you are not trying to logic or reason with
the client at this point. Your only goal is to help them reduce their level of anger and agitation.
Work to understand the client’s perspective and communicate to them that they are being heard. Allowing the client
to air their grievances without judgement is o�en enough to defuse the situation. 
Do not get loud or try to yell over a screaming person. Wait until he/she takes a breath; then talk. Remember to keep
your voice low and calm.
Respond selectively; answer all informational questions no matter how rudely asked, e.g. “Why do I have to do this
g-d homework?” This is a real information seeking question). DO NOT answer abusive questions (e.g. “Why are all
teachers (an insult?) This question should get no response whatsoever.
Explain limits and rules in an authoritative, firm, but always respectful tone. Give choices where possible in which
both alternatives are safe ones (e.g. Would you like to continue our discussion calmly or would you prefer to stop
now and talk tomorrow when things can be more relaxed?) Do not make threats or give ultimatums.
Suggest alternative behaviors where appropriate e.g. “Would you like to take a break and have a cup of water? Give
the consequences of inappropriate behavior without threats or anger.

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60281/verbal_de-escalation

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60281/managingangerinclients

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60281/managingangerinclients

Remind the client that you are their to help. The client may be presenting as angry as a result of things out of your
control or may simply be angry at the current situation. As the social worker, you may be seen as part of the
problem. It can be helpful to remind the client of your helping role. Whether it is to advocate for the best interest of
the client or children involved, it is important to remind the client that you are working together. 

Key Takeaways
Radiate calmness
Convey genuine interest and empathy
Set respectful, clear limits
Stay safe! Be aware of any resources available for back up and crisis response procedures.
Trust your instincts. If you assess or feel that de-escalation is not working, STOP! Seek help and follow your agency’s
crisis response plan.

5. Social Worker Self-Care

Self-care is essential for social workers. It is necessary not only to recover from the stress of supporting our
clients, but to maintain a baseline level of functioning that keeps you feeling healthy and fulfilled. It’s about
enhancing your overall well-being, not just coping with stress. Neglecting your own self-care leaves you
vulnerable to burnout.

Some symptoms and consequences of burnout:

You may become increasingly rigid at work, struggling to learn and implement new techniques, to accept feedback
from supervisors or colleagues, to adjust to agency policy changes, etc.
Increased irritability and frustration with work. Developing negative, cynical attitudes and feelings.
Feeling physically, emotionally, and spiritually exhausted, as if you have nothing le� to give to your clients or to
anyone in your personal life.
Increased risk of being a victim of workplace violence

In next week’s assignment, you will review the Self-Care Starter Kit from the University of Bu�alo School of
Social Work and create a self-care plan for yourself.  Some key takeaways from the starter kit are highlighted in
this section.

Your self-care plan should be two-fold:

What you value and need as part of your day-to-day life (maintenance self-care)
The strategies you can employ when or if you face a crisis (emergency self-care)

The process of identifying these values and strategies is similar to the Coping phase of the ABC model. You will
first ask yourself what you have done in the past, then you will explore what practices you can add and work to
eliminate obstacles. 

Aims of self-care:

Taking care of physical and psychological health

Managing and reducing stress
Honoring emotional and spiritual needs
Fostering and sustaining relationships
Achieving an equilibrium across one’s personal, school, and work lives

Self-care is not just an individual activity. Organizations can also support safety and self-care for workers. This
podcast explores how nonprofit organizations can create a culture of self-care. 

http://socialwork.buffalo.edu/resources/self-care-starter-kit.html

https://www.insocialwork.org/episode.asp?ep=219

http://socialwork.buffalo.edu/resources/self-care-starter-kit/how-to-flourish-in-social-work.html

Accessible transcript of the above infographic

http://socialwork.buffalo.edu/resources/self-care-starter-kit/how-to-flourish-in-social-work.html

https://lsuonline.moodle.lsu.edu/pluginfile.php/159623/mod_book/chapter/60278/How-to-Flourish-in-Social-Work-Infographic-Transcript