DescriptionWeek 3 centers around four main topics1)

Description
Week 3 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

suicide
https://www.npr.org/sections/health-shots/
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?
https://www.suicidology.org/
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_ci
d=mm6745a1_w
https://theactionalliance.org/
https://suicidepreventionlifeline.org/
https://www.sprc.org/
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 determini ng

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
http://cssrs.columbia.edu/
https://suicidepreventionlifeline.org/wp-
content/uploads/2016/08/Suicide-Risk-Assessment-Standards-
1.pdf
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.pdf
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_bo
ok/chapter/60282/Chiera%20Crisis%20Contact%20Note.pdf
ok/chapter/60282/Chiera%20suicide%20risk%20assessment%20
and%20intervention%20form.pdf
ok/chapter/60282/Sarah%20Crisis%20Contact%20Note.pd f
ok/chapter/60282/Sarah%20suicide%20risk%20assessment%20a
nd%20intervention%20form.pdf
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
https://www.div12.org/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 likel y 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/2018N
CVRW_WorkplaceViolence_508_QC.pdf
https://www.socialworkers.org/LinkClick.aspx?fileticket=6OEd
oMjcNC0%3d&portalid=0
https://www.osha.gov/Publications/osha3148.pdf
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=6OEd
oMjcNC0%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.
ok/chapter/60281/verbal_de-escalation.pdf
https://lsuonline.moodle.lsu.edu/pluginfile.php/ 159623/mod_bo
ok/chapter/60281/managingangerinclients.pdf
ok/chapter/60281/managingangerinclients.pdf
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
ok/chapter/60278/How-to-Flourish-in-Social-Work-Infographic-
Transcript.pdf
Student Name: Week 4 Assignment TemplatePart 1 - Suicide
Risk Assessment and Intervention

Scenario A, Sal
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 B, Maria
Desire
Notes:

Capability
Notes:
Intent
expressed intent
Notes:
the future
☐Sense of purpose
Notes:
Risk level
buffers)

Plan of Action
1.
2.
3.
Scenario C, Beth
Desire
Notes:
Capability

Notes:
Intent
expressed intent
Notes:
the future
☐Sense of purpose
Notes:
Risk level
buffers)
Plan of Action

1.
2.
3.
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.)

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