Shamelessly utilize whatever resources you need that will help you be a better therapist.

A major focus of therapy is on preserving and enhancing client well-being, and their safety is a core component of this. In many jurisdictions therapists are obligated to report certain types of information in an effort to preserve client safety, though the specifics vary by region. You need to be familiar with your local informed consent guidelines and obligations to report. We need to know what to listen for (risk factors) and when and how to ask more about them (risk assessing), and when necessary, how to safety plan. The following are suggestions to make this easier for you; they not exact clinical instructions to follow, see the disclaimer for more info.

Depending on the level of severity of a risk, it can be very important to remember to assess certain points. There's lots of reasons a person might miss a detail: bias, distraction, burnout, anxiety, panic, being in a rush etc—any of which could have serious consequences. Newer therapists are probably more prone to the anxiety and stress based issues on average.

Professional obligations vs personal feelings: while it’s normal to feel uncomfortable enacting mandatory reporting, it must occur.

While nothing takes the place of formal training and experience, I help myself with this by having reference lists on my phone, so when I might be missing something I can check it. Most of the time I do a good job with assessing and safety planning, but I don’t want to make a shitty safety plan because I was tired or stressed out and forgot something. You could print the list as well; I am in other people’s offices temporarily assisting so having it on my phone is more reliable.

My reference lists are very concise, updated as needed, and contain locally relevant community resources. I like to use a free app that sync’s between my devices, because I find editing it easier on a computer (I use ‘standard notes’ currently, it’s free, multi-platform, open source, and encrypted).

I keep separate pages for each context, and within each I have a breakdown by risk factor, risk assessment questions, and safety plan options. Currently I have pages for suicide/self harm, domestic violence, and child welfare which is broken down further depending on if I’m speaking to an adult or child. For example, here’s a version of my DV one:

Risk assessing domestic violence:

• Do they have any children? Name + DoB of oldest? (How my jurisdiction identifies families)

  • Almost any time a client mentions they have a child, they can see I’m drawing a genogram and I casually ask “and when’s Jimmy’s birthday? And what school’s he at?” and write it down in the first session like it’s normal, which it is. Absolute life saver sometimes

• Does the client feel safe going home with/to this person?

• Frequency and type of abuse, weapons involved etc?

• Ask about escalation over time from arguing to criticism, yelling, swearing, hitting table, throwing things, punching holes in wall, blocking doors

• Where are children during this behaviour?

• Substance use?

• History of police involvement?

• Have you left this person before?

• Have they threatened you, or to harm themselves?

Safety planning domestic violence:

• Generally asking them what they need to feel safe and how I can help

• How will they know/decide they need to enact part of this plan?

• 1 to 5 scale of severity, behaviours at each number and what's needed based on intensity

• Safe, alternative place they can stay agreed on beforehand with friend/family

• Extra person who can check in, regularly, daily of possible. Extended family, neighbour etc. Could have secret signal for “I need help call 911”- someone who you can call for support, and local 24 hour distress lines- are they willing to call 911 if needed?

• Contact info for local shelters, free childcare for overwhelmed parents, any good stuff your community has. If you don’t know about it ask peers and call a few local places when they’d be slow]

• Give relevant local resources like crisis call lines

• Help them feel more comfortable accessing resources, possibly calling the line together on speaker during the session to get them familiar with what it’s like and what the service does

• Have a “Go bag” ready or in the car- Hide extra clothing, house keys, car keys, money, etc. at a friend’s house- Have a scan/copy of important documents (id, prescriptions etc) stored somewhere else

Again, I have more reference lists for suicide/self harm, domestic violence, and child welfare.

I rest easier knowing these lists are with me. Safety is something most therapists have to deal with frequently, so while it does become more ‘normal’, the cost of missing a detail is too high. Then when you start getting extra systems involved (paramedics, after hours call with child services etc) on a day you’re tired… It’s just the reality that we can miss things if we don’t have a system to help us. Client safety is generally the priority above all else.

Shamelessly utilize whatever resources you need that will help you be a better therapist. For starters, many localities already have these kinds of lists for their area. I often find them for family shelters and similar, and this can be a good starting point. 

Lots of therapists believe that there are some decisions you shouldn’t make in isolation, like hospitalizing a client or breaching confidentiality. I have the luxury of working in a large practice so consulting is simple, but my larger point is it’s normal and ethical to consult, assuming there is time. No getting around it, this one can be uncomfortable. It’s a question of “when”, not “if”. Take a moment to feel bad for my students who have had it happen in their first week!

Prepare, consult, do your best, and take care of yourself.

Disclaimer again: this information is for educational purposes only, and when dealing with client safety always prioritize local laws and licensing guidelines. Consult your supervisor and licensing body as you make/finalize these lists for yourself if you think they’d be useful. Your local training program must have covered risk assessing for suicide etc, and if it didn’t then you shouldn’t see clients until you get formal training—do ASSIST or similar. This article is to make the process easier and more thorough; it does not to replace good training and supervision.

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