A client was recently assigned to me, and when I contacted her to set up an appointment she told me she had been in the hospital a month ago because of suicidal thinking. I’m not sure whether I should take on this client since I’m in a practicum and have only seen clients for a few months. What should I do?

It is a very good idea to ask the question of whether a client is appropriate for treatment with you before you begin with anyone new. This situation poses particular challenges because of the client’s recent suicidal thinking, but it is a good idea to take some time to evaluate that question with all new clients assigned to you. I will outline some factors to consider in the evaluation of your client’s risk.

Since you are in a practicum setting, the first step is to consult with your supervisor. She/he needs to know about your client’s hospitalization to determine whether she/he is comfortable supervising the case and proceeding with an initial appointment. If not, you’ll get suggestions on how to refer her to another resource either within or outside your agency. If you get approval to schedule an initial appointment, ask for your supervisor’s guidance about how to make an evaluation that will guide your decision to proceed with ongoing treatment.

Some of the factors I would consider in evaluating your client’s risk and the appropriateness of outpatient treatment are 1) her history of suicidality and hospitalization, 2) her ability to describe the precipitants and current strategies for managing suicidal thinking, 3) her level of engagement in treatment, and 4) the availability of other resources both within your agency and outside. I will discuss each of these factors briefly.

Your client’s history of suicidality and hospitalizations will assist you in determining whether you can help her to manage her symptoms on an outpatient basis. Her risk is lower if this was her first episode and is greater if she has had prior episodes especially if they occurred within the last year. Another area for evaluation of risk is her ability to describe the suicidal episode with some insight into the contributing factors and how she will manage suicidal thoughts that may recur. You’ll want to know whether she has a safety plan and how she has used it since being discharged from the hospital. Outpatient treatment is likely to be more successful if she has developed some insight into the recent episode and if she has strategies for managing recurring symptoms. Some clients adopt an attitude of distance from their symptoms after a hospitalization and are unwilling to talk about a safety plan, stating things are different and the symptoms aren’t going to recur. Although it may seem reassuring to hear this from a client, it is actually indicates a greater risk of future escalation.

While you are meeting with your client, you can assess her level of engagement in treatment by noticing whether she interacts with you in a collaborative manner and has ideas about her needs and plans for using therapy. If she is more passive or doubtful about the usefulness of therapy, it is less likely that you’ll be able to work with her productively. This is especially true if she is unable or unwilling to access other resources in addition to your individual outpatient treatment. Seeing a psychiatrist for medication management, attending a support or psychoeducational group, engaging in couple or family therapy, and/or receiving assistance with financial and housing needs are often vital to the success of therapy with someone who is recovering from an episode of suicidality.

A final step I recommend in evaluating the appropriateness of this client for your case load is to reflect on your experience with suicidality in your personal life as well as in a professional or volunteer capacity. This case may bring up past memories and difficult feelings if you have personal experience, and this is an area to discuss with your supervisor before and after your initial session. At some point, you will need to face this area of difficulty, but you should do this at a time that you feel as prepared and supported as possible.

I hope you find this helpful in evaluating the appropriateness of a client for treatment. Please email me with comments, questions, or suggestions for future blog topics.