3 Tips for Managing Client Crisis in Private Practice: Tools for Successful Safety Planning
Are you prepared if one of your clients is in crisis?
Some of us have background working in crisis centers, emergency rooms, inpatient units, and community mental health, where we are used to higher acuity clients who may cycle in and out of crisis. Perhaps this is an area you’re very comfortable with and enjoy working with this population. For others, you may have been less exposed to workplace settings in your internship, practicum or employer prior to going into private practice. It can be hard to know exactly what to do and how to help keep your clients safe, all while disrupting rapport as little as possible.
As a result, you may take on a limited number of clients who experience crisis to balance out your caseload, or you simply prefer to refer out to clinicians with more comfortability or experience working with these clients so they aren’t on your caseload. Unfortunately, a crisis can happen to anyone at anytime. It doesn’t discriminate and it’s crucial you know what to do, feel supported, and have the appropriate resources for navigating this with your client.
How I can help
I’m Michelle Solomon, LICSW, owner of Roots of Compassion Therapy, and I come with almost a decade working in inpatient behavioral health settings at four different hospitals in King County. I’m very familiar with crisis prevention, how to assess and refer clients to higher level of care, and safety planning/suicide prevention. Feel free to visit my professional consultation page for more information if you’re interested in discussing a specific case. Here we’re going to talk about 3 crucial tips to help you feel more confident and supported when your clients experience a crisis.
Let’s start by defining crisis
When I worked inpatient, the primary crises typically included, but were not limited to: suicide attempts or inability to maintain safety, manic/depressive/psychotic episodes, panic attacks, and distressing life events. In private practice with clients, crises are sometimes as simple as feeling anxious all day, not getting enough sleep, or feeling overwhelmed and burned out at work. Examples of events that can turn into crises can be losing a pet or family member, getting injured, or experiencing a lay off. These present differently and hold different meaning for everyone, and it’s important to understand the severity for each person. Feeling anxious all day for you may be manageable with support from a loved one, exercise, and deep breathing, but for someone else, that might mean they miss work, skip meals, and don’t leave the house. These warning signs with how crisis manifests for your client could be a signal that they may need a higher level of care.
What types of crises have your clients experienced? Did you feel equipped to handle them when they arose?
For the sake of this post, we are going to talk about crises related to safety, including suicidal thoughts, harm, or urges and challenges with safety planning. Before I share my 3 tips, I want to preface by saying all of these are also appropriate to use if your client is NOT in active crisis. Active crisis occurs when someone is having Suicidal Ideation (SI) with intent to act on it or a suicide attempt. You may find a client will reveal something that indicates they are in active crisis during any of the steps laid out below. If you already know they are in active crisis, it’s imperative they go to the emergency room to be evaluated, I strongly encourage you to make a plan to help them take the next step. If they aren’t in active crisis, please read on for my recommendations.
Here are three tips to support your clients experiencing a crisis:
Initiate a Family/Support Meeting:
Some clients will be comfortable with this, and others won’t. Including a support person may be a boundary you hold in order to keep working with them, especially if you have genuine concerns about their ability to keep themselves safe and they aren’t too keen on going to the emergency room for a psychiatric evaluation. If they aren’t comfortable with this, what are they comfortable with? So much feels out of their control, so offering choices can be helpful, when appropriate. For example, your client may respond well to having you talk with the support person on their behalf. Or they might choose to have a meeting all together with you and the support person. Finding ways to offer options during crisis can give your client a sense of autonomy and control over their own care plan.
What if there is no support person? They may feel there is no support person if they’re feeling depressed or not on great terms with people in their life, but that doesn’t necessarily mean there is no support. Could it be someone they aren’t currently close with, but in a safety situation it makes sense to include them?
If there truly isn’t any support, I suggest identifying who is part of their treatment team to loop into a support meeting. Perhaps they have a case manager, medication provider, and/or a job coach. Discuss plans with your client, and again, offer them the choice for you to meet separately or for them to join. It would be recommended for your client to participate, but if there is resistance and the only option they are open to is for you to meet without them, then proceed with their consent at that level. You can also set expectations by letting them know things may change after speaking with the team, and learning how the team decides to engage in safety planning. This prevents your client from being blindsided by the possibility of a group meeting being suggested. Ultimately, looping in at least one support person is extremely important for safety planning and crisis management, making sure this person is aware of your client’s safety concerns, and to help reduce triggers or access to means for your client.
2. Use a 1-10 Scale:
This is one of my favorite tips and can be applied for a variety of examples. When I worked with patients preparing to discharge, I would often ask what their SI was on a scale of 1-10. I would also compare that to their baseline to see how close it was. If they had baseline SI at a 3 and at discharge they were at a 4, compared to hospital admission at a 7, that is a significant improvement. I would also follow-up by asking their intent or how likely they would act on any SI and how safe they feel about discharging, both on scales of 1-10. This would give me a good indication of readiness to discharge. Transferring this to use in private practice, you can ask questions in many forms and engage in curiosity and motivational interviewing to explore further. Some other examples include:
How strong are your negative thoughts on a scale of 1-10
How committed are you to following your safety plan on a scale of 1-10?
How confident are you with not acting on any SI on a scale of 1-10?
What do you need to lower your SI from a 4 to a 3?
Another way I love using the 1-10 scale is related to coping skills. When I safety plan with clients, I make sure we aren’t just brainstorming any coping skills, but what coping skills they can do when their SI is low or at a 1-3, medium at a 4-7, or high at an 8-10. The reality is what your client does at an 8 will look vastly different than what they do at a 2. When SI is lower, clients may be able to do some thought challenge, journal, exercise, meditate, call a friend, or walk. When the thoughts are more intense, it’s likely going to be utilizing crisis services, such as a crisis line and going to the emergency room. Again, crisis looks different for everyone. For some, they may need to engage in calling a crisis line at 6, where as others it could be 8. No matter your approach to the 1-10 method, your primary goal (other than client safety) should be to determine your client’s ability to keep themselves safe and which level of care is appropriate for them (inpatient, residential, PHP, IOP, or continuing with you in an outpatient setting).
Do you know this for your client? Have you done safety planning with this scale in mind?
3. Therapy Must Go on Hold:
This may sound self-explanatory, but I think it’s important to be said. Prior to the crisis, you may have been doing some incredible work processing trauma, using a particular modality, or perhaps focused on one of your specialties for which they are seeing you and not someone else. While all that is great, if your client is in crisis, your therapy work needs to be on pause while the crisis gets sorted out. Take time to pause and be transparent with your client about your safety concerns. Shift the focus temporarily to prioritizing and addressing the crisis. It can help build rapport when it’s clear what you are doing and why. I realize this may be uncomfortable, frustrating, and could impede their progress with their goals, but pausing is a necessary step to ensure your client is safe.
If your client isn’t happy with focusing on crisis prevention steps, that’s ok too. You aren’t doing anything wrong, and them being upset with you is a normal reaction for someone in crisis. Safety > Rapport. The rapport has good potential to return, and you can resume your therapy work once the crisis has simmered down and your client has stabilized. It’s not a guarantee, and very possible you may need or decide to refer out for various reasons, but know that you are taking the right steps and following your ethical duty to keep your clients safe.
Are there any steps you’ve tried? How did it work for you? Which one might you want to incorporate the next time you are working with a client in crisis?
Resources, 1-1 professional consulting support, and more
I hope this served as a helpful tool with some tips and recommendations for navigating safety planning with your clients. If you are looking for more 1-1 support on a specific case, have other questions, or want to educate your team, I offer professional consulting and curated workshops related to crisis and suicide prevention, safety planning, boundaries to set with high-risk clients, and how to transfer and when to refer. Please explore my professional consulting page for more information to get started!
In addition to 988 (National Suicide Hotline), the Inclusive Therapists has some wonderful resources and warm lines that don’t involve the police and can be helpful alternatives, especially if your client hasn’t had a positive experience with 988 or the police. Please note: these warm lines are not 24/7, and it’s important that your clients are aware of this and have access to 988 in the case they need support outside of warm line hours.
