Section 2: Recognise and Respond to Crisis

Submitted by sylvia.wong@up… on Fri, 12/09/2022 - 00:40

In this section you will learn to:

  • recognise and respond to indicators of risk
  • identify and begin assessing risks to clients
  • respond to identified risks and crises.

Supplementary materials relevant to this section:

  • Reading D: Understanding Risk and Protective Factors for Suicide
  • Reading E: WA DFV Common Risk Assessment and Risk Management Framework

In the first section, you learnt about key considerations that counsellors need to take into account when working with clients who may be at risk or in crisis. With these in mind, we will now look at the skills and processes that counsellors use to recognise and respond to these situations.

This usually begins with observing client behaviours and considering their responses to questions. Where safety concerns are identified, further risk assessment is required, and the counsellor will need to work with the client to reduce immediate risks and help them connect with appropriate support. This section focuses on two risk situations that are often associated with crisis and a high level of stress in a counselling context – suicide and DFV.

Sub Topics

In order to make sure counselling is suitable and safe for a client, counsellors need to gather information sufficient to develop an understanding of the client’s circumstances and capacities, including whether they may be at risk or in crisis. Most often, the information you need will be gathered by observing the client’s presentation and behaviour and asking appropriate questions.

Reflect
Are you able to recall the indicators of risk we discussed in Section 1? If you need a refresher, return to Section 1 and review the relevant content before moving on. Remember, many of these situations share similar indicators, and some risks are themselves indicators of further risk.

Observing and Asking Questions

How a client appears, speaks, moves, and responds to you are all forms of communication. Therefore, they will be giving you information from the very first moment you see them (which you must effectively receive and interpret). Throughout your conversations, the client will also give you information about how they think through their verbal and non-verbal behaviour, including responses to your questions, their tone of voice, and their body language as they speak, listen, and think. All of these observations will help you to form an impression of the client’s situation. You need to pay attention to any inconsistencies between their verbal and non-verbal behaviours, as that often warrants further assessment of safety concerns that may otherwise go unidentified.

In Section 1, you have learned about indicators of various risks, including DFV, child and elder abuse, suicide, and self-injury. Remember, signs of risks differ between clients and sometimes the signs will be very subtle or well-hidden. Because indicators can be ambiguous, you will need to explore what they are indications of in the particular client’s case. However, these indicators alone are not enough to identify and determine risks or crisis. Instead, they should prompt you to seek further information. Typically, this is done by asking appropriate questions and/or using appropriate assessment tools.

Counsellors use various questions to gather information about client issues and life circumstances, including gathering specific details for assessment purposes. For instance, a counsellor may begin with general, open questions such as 'What can I help you with?'or'What has brought you here?' to get an initial sense of the client’s presenting issues and to start eliciting information that could indicate areas for further inquiry. They may also ask broad questions about the client’s safety, such as 'Do you have any concerns about attending counselling?' or 'Do you have any concerns for your safety?'and follow up with more specific questions as the client discloses relevant information.

Importantly, whenever there are any signs of potential risk issues – even when this is just a ‘hunch’ – you must seek clarification with the client, using a gentle and respectful questioning approach. For instance, if you notice that a client starts picking at her fingernails when discussing her partner; you might check with the client by asking, 'I notice that you seem uncomfortable – or maybe nervous – when we talk about your relationship with Sam. Can you tell me more about what’s happening for you?'. When pointing out your observation, it is important to be respectful and tentative, instead of making assumptions about what is behind the signal you have observed or putting your follow-up questions or reflections in wording or tone of voice that could convey disrespect or judgement. Even if you are fairly certain that the fingerpicking is a sign of anxiety, for example, it would not be appropriate to say, 'I can see you’re very anxious. You have an anxiety disorder, do you?' or 'Why are you picking at your fingers like that?'. Questions that indicate judgement or assumptions are problematic and can drive distress or defensiveness in clients.

Screening for Risk

It is now usual practice in human services organisations to screen each new client for indicators of risk. Counsellors (and other helping professionals) regularly ask general questions about risk and safety at the initial stage of client work. For instance, a counsellor may say, 'Before we start, we have a few questions to work through that we ask all our new clients.'

Having normalised the process, they will then ask a few questions aimed at identifying potential risks, such as, 'Are you concerned about your safety at any time?', 'Do you have any worries about your safety at home?', 'Do you have any concerns about your children’s safety?', 'Have you ever had thoughts about harming yourself?', or other similar questions. Of course, it is critical that counsellors are gentle and sensitive when asking screening questions.

If you are using a screening tool or intake form, make sure that you use it as a general guide and conduct screening in a conversational manner. Do not simply run through the list of questions; instead, gather as much information as possible during the normal flow of conversation, and then ask specific questions about areas where you need additional information. For example, asking a client to 'Tell me about what home is like for you,'is likely to elicit quite a bit of information about the home environment, who lives there, and whether the client is living with a spouse or children; similarly 'What has been happening that has brought you here?'will probably lead to a response with a lot of details you can enter on an intake/assessment form without having to ask about every single item separately. You can then ask more focussed questions about any area where you need information beyond what the client has already provided.

Remember that the form or tool should serve only as a general guide for the minimum information to be gathered. You must remain aware that you may need to explore areas the form does not cover – after all, no single tool can possibly cover every client need. You should aim to develop competency in using the form, adapt its use to the client’s circumstances, and use it in combination with your professional judgment. For instance, when the information gathered indicates a lower risk level than your professional judgement suggests, you may elevate the risk level indicated by the assessment tool. However, professional judgement must not be used to reduce an indicated risk level.

For example, a client’s level of fear is a useful indicator of elevated DFV risk, so if a client appears to be at low risk according to the risk assessment tool but reports feeling extremely fearful, seriously consider elevating the risk level. However, a client’s lack of fear must not be used to reduce an indicated or suspected risk level, as some people who experience DFV seriously underestimate the risk they are facing. And, as always, assess the risk and respond to it in consultation with your manager or supervisor.

Before we move on, it is important to note the difference between screening and risk assessment. Screening refers to a brief process whereby workers seek to identify whether a risk is present so that appropriate action can be taken if one is found (Robinson & Moloney, 2010). Routine screening should be carried out to increase the likelihood of identifying risks that may otherwise go under the radar. Where risk is identified, risk assessment is carried out to explore the type and severity of the identified risk, and occurs whether the risk is identified through screening or other means.

Assessing Risks and Related Problems

Once a counsellor has identified that a client may be in crisis or a safety issue may be present, they will generally undertake a further assessment in order to better understand the nature of the risk and identify appropriate responses to it (the exception being when other actions are needed to enhance safety, such as immediately contacting emergency services). This typically involves assessing the severity of the risk and how the client is managing it (e.g., coping mechanisms, support system, and other resources available to the client). For instance, a counsellor may ask questions such as:

  • When did the problem first occur?
  • What else was/is going on?
  • How did your family or friends react?
  • How often has this happened?
  • When was the problem at its worst?
  • Have you asked for, or received, any help before now?
  • When was the last time it happened?
  • How did you handle it?
  • What did you do to try to help yourself?
  • What prompted you to seek help now?

During this process, it is important to explore the situation calmly and empathically with the client. While there is often a sense of urgency to seek details about the crisis or risk situation, counsellors must be mindful of the urge to engage in a ‘problem-solving’ mode. Instead, the goal is to provide a safe environment for clients to talk through what is happening so that they begin to feel more in control and able to make positive decisions and access help to take appropriate actions (James & Gilliland, 2017). The following skills are important during this process:

  • Remain calm and empathetic.
  • Focus on the client and their understanding of the situation.
  • Attend to the client’s verbal and non-verbal messages (i.e., what the client does not say can be more important than what is actually spoken).
  • Display appropriate body language and vocal tone to assist the client in remaining calm and feeling safe.

Listening calmly and empathetically is also vital to developing trust and rapport, which is required for effective counselling in such situations.

Use of these basic rapport-building communication skills invites clients to talk, brings calm control to the situation, allows them to talk about the facts of the situation, helps the counselor to hear and empathize with the client’s feelings, and lets the client know that the counsellor is concerned and respectful.

(Kanel, 2015, p. 50)

At times, you will need to ask questions that you or the client may feel uncomfortable with. For example, it is natural to feel discomfort at first when asking a client about whether they are safe, whether their children are at risk, or whether they engage in self-harm. However, it is critical to be able to do this and to do so in a way that is respectful, professional, and supportive. Therefore, let’s take some time to study specific techniques and knowledge that will help you build competence in exploring these sensitive areas.

Check your understanding of the content so far!

Assessing Suicide Risk

Depressed woman sitting on the therapist couch, mental health concept

Assessing suicide risk relies on your ability to engage the client and sensitively ask challenging questions, as well as on your client’s ability and willingness to answer accurately. Questions about suicide risk must be asked sensitively but directly. This means using direct and clear terms such as ‘suicide’ or ‘ending your life’. Avoid terms like ‘harm’, ‘risk’, or ‘hurt’ as they do not directly enquire about suicide; they are ambiguous and could mean anything from drinking alcohol to scratching one’s skin, to suicide, and a whole host of other things as well. This can lead to client answers that are unhelpful for risk assessment purposes. The following table outlines some general ‘dos’ and ‘don’ts’ when attempting to identify and assess suicide risk.

Do's and don'ts to identify and assess suicide risk

Do's Don'ts
  • Practice using clear language (e.g., ‘suicide’) and asking questions aloud. Continue until you feel confident that you can do so calmly when in conversation with clients.
  • Combine a supportive, gentle tone with clearly stated questions about suicidal thinking, actions, and other risk factors/warning signs.
  • Remember that, if a client is at risk of suicide, they will be feeling distressed. Assessing suicide risk is stressful for the worker, but it is your responsibility to be professional and supportive as the two of you explore what the client is experiencing and the potential risks they face.
  • Do not avoid the term ‘suicide’.
  • Do not use stigmatising or otherwise problematic terminology.
  • Do not ask questions or use language that is unclear, vague, ambiguous, or could be misunderstood, e.g., 'Do you think you might hurt yourself?'
  • Do not ask questions that make clear that you want a negative answer, e.g., 'You’re not thinking about suicide, are you?'
  • Do not ask questions or use language that suggests negative judgements, e.g., 'I hope you’re not thinking about doing something silly/selfish.'

It is highly advisable to work suicide screening into your usual assessment process with new clients and to review it as appropriate over your period of work with each client. For example, you may ask questions such as:

  • 'Some people who seek counselling have thoughts of ending their lives. Have you had any thoughts like that?'
  • 'At the beginning of counselling, I ask about potential risks to clients, for example, "Do you ever think about suicide?"'.

Even if the client answers ‘no’, you must be aware of the potential for this to be incorrect and for suicide risk to develop over time. Because of this, you still need to consider the possibility of suicide risk and watch out for warning signs throughout the counselling process. If you identify a warning sign or have a hunch that the client may be at risk, it is important that you attend and ask gently, directly, and specifically about suicide. As with screening questions, do so in a normalising manner (Sommers-Flanagan & Shaw, 2017), for example:

  • 'Among men who have experienced the loss of a relationship, suicide is a concern. Have you had any thoughts of ending your life?'
  • 'You’ve mentioned that you’re feeling really stuck at the moment, and feeling as though you’re struggling to find a way out. Sometimes when people feel that way, they have thoughts of suicide. Have you had any thoughts about suicide?'.

Where thoughts of suicide are present, or there are other grounds for concern, it is important that you explore further to assess for threats to the client’s or others’ safety.

In general, suicide risk assessment should cover warning signs and other matters relevant to suicide risk. The following table details the important areas to cover in any risk assessment process. Sample questions and prompts are also provided (note that these are simply examples and do not constitute a full risk assessment). Be aware that the term ‘means’ in relation to suicide refers to the things the person would need to carry out a suicide plan.

Areas of assessment Example questions

Suicidal thoughts

The desire for death, even without specific thoughts about suicide can indicate risk. The desire for death combined with thoughts about suicide is extremely concerning. Lack of fear of death or pain can indicate raised risk.

  • Have you been thinking at all about suicide?
  • Have you been having thoughts about death or dying?
  • How often are these thoughts happening?
  • How long do the thoughts last?
  • How long does this kind of thinking happen for?
  • How intense/powerful are the thoughts?

Suicidal intent and will to die

Intent to suicide indicates that the risk is very high.

  • Do you intend to end your life?
  • On a scale from one to five, where one is absolutely not going to happen and five is definitely going to happen, how likely would you say you are to suicide?
  • Do you intend to act on any of these thoughts about suicide?
  • Do you want to die?

Suicide plans

Having a present or previous suicide plan raises the risk level. Where there are identified means and/or methods, higher lethality (i.e., the likelihood that it will result in death) of the method and availability of means are associated with increased risk.

  • Do you have a suicide plan?
  • Do you have any ideas about how you would go about ending your life?
  • Have you had a suicide plan before?
  • Do you have/Are you able to get [means]?

Previous suicide attempts

Previous suicide attempts indicate increased risk.

  • Have you ever attempted suicide before?
  • How did you try to end your life?

Suicide preparation

Taking action (e.g., gathering or pre-paring means; putting affairs in order; saying goodbye) to prepare for suicide indicates high risk.

  • Have you done anything to prepare for death?
  • Have you made any arrangements? For example, have you put some of your affairs in order, drafted or changed your will, said goodbye to anyone, or done anything else to prepare for dying?

Other warning signs

Warning signs such as emotional distress, cognitive issues, difficulties relating to particular circumstances, and various behaviours can indicate potential imminent and serious suicide risk.

You will need to be prepared to ask questions about specific factors, circumstances, risk indicators, and concerns.

  • You’ve mentioned serious emotional pain. Would you tell me more about it?
  • On a scale from 1, which is completely hopeless, to 10, which is totally hopeful, where would you rate your level of hope at the moment?
  • I wonder whether you’ve noticed any changes in your routines, habits, or things that you usually do. … Are you having trouble sleeping, or getting more or less sleep than usual? … Do you find yourself withdrawing from friends or family?
  • Do you feel as though you’re out of control at the moment?
  • Have you been doing risky or impulsive things recently?
  • Have you been using alcohol or other drugs at all?

Suicide risk is a complex area. In addition to warning signs, developing an understanding of risk factors (i.e., things that are associated with an increased risk over time can also help you better recognise and assess suicide risk.

Suicide Assessment of Client with Initially Subtle Warning Signs of Suicide

This video features a counseling role-play session that demonstrates a suicide assessment of a client (played by an actress) whose thoughts and warning signs of suicide are initially subtle.

Read

Reading D – Understanding Risk and Protective Factors for Suicide, from the Suicide Prevention Resource Centre, provides a clear explanation of the difference between risk factors and warning signs, and their application in risk assessment. It also introduces the concept of protective factors, which are things that appear to reduce the likelihood of suicide.

Assessing DFV and Associated Risks

Given both the effects of DFV and the unhelpful ideas about it within our society, it can be extremely challenging for people exposed to violence to disclose that it is occurring (or has occurred) and engage with services. In addition, having to discuss their experiences can be intensely distressing and uncomfortable. As such, it is essential to use your rapport-building and supportive skills throughout any work with clients who may be affected by DFV. This holds true whether the client-counsellor relationship extends across a lengthy counselling process or is as brief as an intake appointment and connection to a specialist service.

People who have experienced DFV have been deliberately made unsafe by another person, so creating a safe space for the client is all the more critical. Here, safety goes beyond a physically safe and confidential space; it also means a counselling relationship characterised by warmth, respect, non-judgement, and a commitment to the human rights and autonomy of the client.

Listening to and believing the client can be a moving and liberating experience for someone who is living with fear or with little personal autonomy. Two reactions are common when clients disclose and are heard – surprise that others are experiencing what they are experiencing, and relief at being believed. Communicating belief is important in engendering hope and as a reality check. ‘That sounds very frightening for you’, for example. It is also helpful to endorse the decision to disclose, ‘I know this is very difficult to talk about, but I am glad you did.’

It is also important to be clear that abuse, violence, humiliation, or threats are unacceptable. It is important to be explicit that violence and sexual abuse within a relationship are crimes, and that the responsibility for such crimes remains with the perpetrator, not the client. In naming abusive behaviours as such, use language that the client can relate to such as:

  • 'No one deserves to be treated this way.'
  • 'Do you know that what you are describing is regarded as domestic violence?'

Above all, be aware of your own values and biases. Questions such as ‘Why have you stayed so long?’ or ‘What could you be doing differently?’ are unhelpful and imply shared responsibility for the abuse. A client’s sense of self and safety may be precarious or confused, so it is important they stay in control. Refer to a client’s sense of control by asking, for example, ‘What would you like to deal with first?’ Clients who get respectful, skilled and informed support will make good decisions for themselves.

(Adapted from O’Brien, 2015)

A safe counselling space is also one where clients may discuss these matters only if they so choose and if it is safe to do so. When discussing DFV with clients, it is important that, beyond gathering essential information, you do not expect or pressure clients to discuss the abuse they have experienced. Avoid asking detailed questions about the abuse and focussing on particular incidents as this increases the risk of re-traumatisation (also called ‘secondary traumatisation’). This is a serious issue that can impact people who have experienced abuse or other traumatic events. The risk is higher when they have to discuss the events or details when it is not helpful to do so and when the responses to disclosure are inappropriate, unsupportive, or judgemental (Seeley & Plunkett, 2002).

In addition, while you are developing an understanding of the client’s experiences, you should also take note of factors that have contributed to their safety and any efforts to maintain others’ safety (e.g., a child’s). Remember your responsibility to be respectful and help the client identify their strengths, including the knowledge, skills, strategies, and other resources they already have.

When gathering information about DFV, it is important to remember that while clients have a great deal of relevant information to offer, they may not have sufficient knowledge about DFV required to communicate important details. This means that counsellors need to be skilled in helping clients identify relevant information to provide. Counsellors need to use their knowledge about DFV in combination with active listening and asking appropriate questions to identify risks and concerns. For example, a counsellor may ask:

  • 'I heard you say that you were hurt by Patrick. Hurt can mean a few different things, so I’m wondering how Patrick has hurt you?'
  • 'When you say you’re ‘worried about the kids’, is there something in particular that you’re worried about?'
  • 'You’ve said that things are okay at home right now; at the same time, I heard a note of worry in your voice. What is happening that has you worried?'.

It is also important to think carefully about how you phrase your questions, as the way the questions are asked may either bring forth or limit further information. For example, asking whether a client’s partner has ever harmed their child may be answered with a ‘no’ because the client has never seen their partner physically assault the child. We know that terms such as ‘violence’, ‘abuse’, ‘harm’, and ‘hurt’ are not limited to the physical, but many people do not know that these are limited to the physical, and other experiences can be missed due to misunderstanding this, too.

Let’s take a look at a couple of examples from the experience of DFV practitioners, to see how important an issue this is. A person using violence may beat their partner with a belt, but a question about whether their partner has assaulted or threatened them with a weapon can result in a negative answer because the client is not aware that in this context ‘weapon’ refers to items that are used to harm others, not just ones that were designed to do so. A client may be coerced or forced into sexual activity, but a question that focusses on ‘sexual assault’, ‘sexual violence’, or ‘rape’ may not elicit this information, because the client does not realise that what they have experienced meets the definitions of these terms. Where a question is not understood, critical information may be missed. At the same time, it is important to avoid asking leading questions or making assumptions.

DFV & Trauma-Informed Practice: Why it Matters

This video discusses the importance of DFV & Trauma-Informed Practice.

Reflect

In assessing DFV risk, you will need to ask questions that are, at times, intensely personal and potentially distressing.

How comfortable do you feel asking about a client’s experience of abuse? Do you feel confident asking questions about sexual violence? Do you think you can sensitively ask a client about harm experienced by their children?

Remember, clarity is essential, but being sensitive in your use of language is important, too.

Check your understanding of the content so far!

Assessing Child-Related Risks and Concerns

Exposure to DFV is now recognised as a form of child abuse, regardless of whether the child is the target of abusive behaviours and tactics. In addition to often being directly targeted and experiencing the types of abuse we outlined in Section 1, children experience significant harm from being exposed to DFV perpetrated against others, such as living in a house where one parent abuses another. In addition, abusive behaviours and tactics are frequently used to control, manipulate or psychologically damage the other parent. As such, it is critical that you assess for child-related risks with the safe parent (usually their mother) and take the child/ren’s safety into account, whenever a DFV risk is suspected or identified.

It is also important to take a sensitive and sensible approach when exploring clients’ concerns about children. Many parents may feel tremendous guilt about their children’s exposure to DFV; others have little understanding of the effects of DFV on their children. As such, you should:

  • acknowledge that discussing harm to child/ren can be upsetting and difficult
  • reassure them that the person using DFV is responsible for the harm done to the child/ren
  • affirm the parent’s efforts to protect and care for their child/ren
  • be aware that the client cannot be with the child/ren at all times, so there may be issues and risks for the child/ren that they are not aware of
  • where appropriate, help the parent increase their understanding of the effects DFV has on child/ren.

An important reminder is that the risk of harm can begin even before the child is born. DFV often escalates during pregnancy, and pregnancy is a higher risk indicator. Violence during pregnancy can result in serious injury to the pregnant person, miscarriage, stillbirth, infant mortality, and health problems for the child after birth (Heward-Belle, 2017).

When asking the safe parent about child-related risks and concerns, questions may start broad, with a narrowed focus as information is disclosed. For example, you may ask:

  • broad opening questions, such as 'Do you have any concerns about your children?' or 'Are you worried that your children could be at risk?'
  • what the client has seen in the behaviour of the person using DFV that causes them any concern, for example, 'Has [person using violence] done anything to or in front of the children that worries you?'
  • any changes in the child/ren’s behaviours or what they said. For example, 'Has [the child’s] behaviour changed, or have they said or done anything that suggests to you that they are distressed?'.
Simulation Scenario - Adolescent Risk Assessement

This video demonstrates an adolescent psychiatric risk assessment, focussing on risk of suicide and self harm and assessment of mental state. This could be used prior to simulation training as a stand-alone or part of a course to demonstrate best practice.

Reflect

As you can see, it is necessary to draw upon knowledge of the effects of DFV on children to check with the client regarding signs of distress or other DFV effects on children.

Reflect on your knowledge about DFV and its effects. How confident are you in your ability to identify signs of distress or risk in your client and their children? How comfortable do you feel asking about child abuse or related concerns? Who will you seek consultation from when you are concerned about child welfare?

Read

Reading E - Western Australian Family and Domestic Violence: Common Risk Assessment and Risk Management Framework

Identifying and responding to DFV and associated issues is a crucial skill that counsellors must continuously develop throughout their practice. Reading E is a great place to start. It outlines some key considerations in risk assessment and has very useful practice tips.

Feeling sadness. Young frustrated man solving his mental problems while having therapy session with psychologist

The appropriate actions to support clients in crisis will differ depending on the type and level of risk the client or others are exposed to, and on the other factors at play. As a counsellor, your goal is to assist the client in identifying and agreeing to specific actions that reduce any immediate dangers and help address the risk situation, in as collaborative a way as practicable. In particular, focus on understanding factors that have contributed to the crisis or risk, and the strengths and resources the client has. You may engage the client in discussions that seek to:

  • validate the client’s experience
  • reassure the client that you are there to help them
  • assist the client in identifying options for support and for meeting their particular needs
  • facilitate client safety.

Remember that clients in crisis can feel overwhelmed or immobilised; it may be necessary for a counsellor to prioritise stabilisation in order to help them get to a place where they can access assistance to meet their immediate needs, make decisions, and start to address the situation. Although generalist counsellors do not typically provide crisis intervention, it is particularly useful for counsellors to be equipped with crisis intervention skills in addition to facilitating access to appropriate crisis intervention or other specialist services. You might remember that Geldard, Geldard, and Yin Foo (2017; in Reading A) suggest the following principles when responding to a client in crisis – deal with the panic and stay calm; normalise the client's experiences; focus on practical responses and assist the client in making informed decisions.

Deal with the panic and stay calm

Because crisis situations are often associated with a sense of urgency and stress, it is particularly important to avoid impulsive actions. Instead, remain calm and empathetic while using all your active listening skills. Be prepared with strategies that you can use (e.g., breathing or grounding techniques) to help you address your own emotions. Help your client to deal with the heightened emotions they feel, too. But avoid telling the client to 'Calm down' or other things that may feel patronising, minimising, or impossible.

Normalise the client’s experiences

This can be extremely helpful as 'people often feel relieved knowing that what is happening to them is inevitable and normal, even if distressing and painful' (p. 264). For example, you may say, 'It’s perfectly natural to feel _____ under the circumstances'. You can also reflect the client’s experience and help them start to regulate their emotions and thoughts. Note: It is not appropriate to normalise thoughts of a psychotic or psychopathological nature; we do not want to reinforce delusions or other problematic cognitions or reduce the sense that specialist intervention is needed in such situations.

Focus on practical responses

You must be clear about what you can and cannot offer to a client in crisis. This will depend in part on the policies and practices of your workplace, and on your training and professional experience, as well as the particular crisis or risk the client is facing. For example, consider a situation where you need to contact emergency services. What are the procedures for doing so? When do you need the client’s permission and when are the limits of confidentiality reached? Who are the other people that you should seek support or advice from? How can you do so without leaving the person alone or on hold? There’s no use waiting until a crisis situation to find the answers to these questions. Instead, think about how you could respond to a variety of situations, including discussing and role-playing potential scenarios and actions with your peers and supervisor.

Similarly, consider a situation where a client is facing a DFV risk. Does your organisation support clients who face this kind of risk? Is this appropriate under your specific role? Do you have specialist training in responding to DFV? Are you trained in using an appropriate assessment tool? Are you up to date with DFV research into risk factors and safety strategies? Is there a specialist service nearby that you can help the client to access? What are their referral procedures? Being prepared beforehand with thorough knowledge of what you can and can’t offer, your organisation’s protocols, and other resources and services will help you to respond appropriately under the pressure of a crisis situation.

Assist the client in making informed decisions

Where safe and possible, we want to encourage the client to consider and decide upon the actions they will take and the support services they will access. If the client identifies a particular service they want to engage with, you can work with the client to develop a plan for how they will access that service, probably with significant assistance from you.

Note that some clients may require more directive support if they are ‘immobile’ (overwhelmed by the situation and unable to think clearly and make decisions). In such situations, you may need to step in by giving clear, concrete directions to the client, especially when intervention is required to fulfil your duty of care. At times, you may also need to take action that is against the client’s wishes, such as notifying emergency services of high or imminent risk or reporting a child safety risk to the relevant child welfare authority, even when the client does not want you to do so.

Ultimately, in all circumstances of risk, there are two things you must do – discuss the risk with a line manager or supervisor and follow any relevant policies and procedures.

1. Discuss the risk with a line manager or supervisor

If a manager or supervisor is not immediately available, you may discuss the risk with an appropriate and more senior colleague, but follow up with your line manager/supervisor as soon as possible. This is something that you should let your client know about in advance, where doing so is practicable and will not increase risk. Your contracting discussions must cover the limits of confidentiality, including the need to consult when suicide risk is identified, so you should have already prepared each client for this possibility.

2. Follow any relevant policies and procedures

Organisational or practice documents should guide decision-making, outline legal and ethical requirements (e.g., duty of care and mandatory reporting) that must be met, and indicate actions to be taken to address various situations. For instance, you may refer to policies and procedures for critical incidents, risk assessment, and referral to emergency services and other supports.

Where risk is minimal, a counsellor may work collaboratively with the client to identify possible support options and appropriate safety strategies, which are often put together as a safety plan. The counsellor should also continue to monitor and assess the risk, as risk levels can escalate quickly. Even when risk levels are low, thorough assessment, documentation, consultation with a manager or supervisor, and ongoing monitoring are required. You will learn more about the steps and considerations involved in safety planning in the next section.

Where risks are higher, legal and ethical obligations and organisational protocols will outline appropriate steps to promote the safety of the client, the counsellor, and relevant others. If the risk is sufficiently high or imminent, appropriate action includes facilitating access to emergency assistance and notifying police or other relevant authorities, even without the client’s consent. This might occur if the client is at risk from others, poses a risk to others, or is a risk to themselves. You must also be aware of the possibility that multiple people are at risk – as mentioned in the previous section. For example, there are instances where people kill others and themselves in what are called ‘murder-suicides’. Similarly, if you are concerned that the client poses a risk to others or that children are at risk, you will need to take appropriate action. This will often involve informing the police and/or child welfare authority. In some circumstances, emergency services will need to be notified before consultation, but in general, your manager or supervisor should be involved in decisions regarding how to respond to risks.

You also have a responsibility for your own safety. In some cases, the physical safety of the counsellor may be at stake, such as when a client threatens or acts violently toward the counsellor, or when a person who abuses or has abused the client approaches the counsellor or place of work. It is therefore important that counsellors are mentally prepared for such situations and are familiar with appropriate practical responses. Your organisation should have guidelines about how to manage potential risk situations, such as using duress alarms, information to acquire from the client, persons or authorities to contact, work health and safety requirements, and documentation to complete. Of course, these guidelines cannot cover all possible risks, but they should provide guidance in responding to a range of crises and risks. Remember, whenever you are uncertain about how to prepare for responding to a crisis or risk, consult with your supervisor or management.

Stopping Suicide With Story

Dr. Sally Spencer-Thomas knows first hand the challenges and stigma we face with suicide prevention and mental health. At the heart of all social movements are stories. Change is possible when we tell our stories. In this deeply moving and personal TEDx Talk, Dr. Sally invites us to join her on a social justice journey and shows us how to shift the culture from the bias and discrimination we currently have, to one of empowerment and dignity; one story at a time.

Reflect

Preparation is important for counsellors to be able to respond appropriately in crisis situations since these tend to happen unexpectedly.

Make a plan outlining the steps you need to take if a client presents in crisis, including how you would seek consultation and support.

A Note About Responding to Child-Related Risks

Wherever there are children involved, you must consider whether any child-related risks exist, regardless of whether the client is seeking support for their children. At times, you may need to report identified or suspected safety risks to the child welfare authority under mandatory reporting or duty of care requirements. You must ensure that you have explained, from the beginning of your contact with the client or potential client, your responsibilities relating to safety, risk, and child welfare. As always, seek support and advice from your supervisor or manager and ensure that you have followed relevant organisational protocols.

In many cases, the client will willingly engage in such a process or will consent to your sharing information with the child welfare authority or police. The client may even like to contact the child welfare authority or police themselves. This is ideal, and you can support the client to do this, such as by helping them decide what to say and offering to help them make the call in session. Even when this happens, however, it remains important to follow up a client report to the child welfare authority with an independent report. In some jurisdictions, this is legally required.

At times, you may discuss such a matter and find that the client refuses to provide consent for information sharing. You may also face situations where child-related risk assessment and safety planning is not possible, practical, or safe (e.g., children may be placed at greater risk if you discuss child safety concerns or your responsibility to make a report with the client). In such cases, discuss your response with a line manager or supervisor, and make reports as required.

In all circumstances where child-related risks have been identified, you must follow the policies and procedures set out in your organisation and consult with your manager or supervisor to develop the most appropriate response. You will also need to thoroughly document the information you gained from the client, all the concerns you have, all decisions made, and all actions taken.

Keeping children and young people safe

A short video on keeping children and young people safe from abuse.

Check your understanding of the content so far!

Throughout this section, we explored key processes involved in recognising and responding to crisis situations, which include identifying indicators of risk, asking appropriate questions, conducting risk assessment, and determining appropriate responses based on the assessment. Importantly, counsellors are not expected to manage a crisis situation on their own. Consultation with the manager, supervisor, or experienced colleague is part of an appropriate response. It is also important to ensure you make responses in accordance with organisational policies and procedures, which will help you meet a range of legal and ethical requirements as previously discussed. The following section will teach you more about responding to crisis situations through safety planning and referral.

Geldard, D., Geldard, K., & Yin Foo, R. (2017) Basic personal counselling (8th ed.) South Melbourne, Australia: Cengage Learning Australia.

Heward-Belle, S., (2017). Exploiting the ‘good mother’ as a tactic of coercive control: Domestically violent men’s assaults on women as mothers. Affilia: Journal of Women and Social Work, 32(3), 374-389. doi:10.1177/0886109917706935

James, R. K., & Gilliland, B. E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.

Kanel, K. (2015). A guide to crisis intervention (5th ed.). Stamford, CT: Cengage Learning.

O’Brien, C. Working with domestic violence: A clinician’s guide to ethical and competent practice. InPsych, 37(5). Retrieved from https://www.psychology.org.au/inpsych/2015/october/obrien

Reeves, A. (2015). Working with risk in counselling and psychotherapy. London, UK: Sage.

Robinson, E., & Moloney, L. (2010). Family violence: Towards a holistic approach to screening and risk assessment in family support services. AFRC Briefing No. 17. Retrieved from https://aifs.gov.au/cfca/publications/family-violence-towards-holistic-approach-screening/export

Seeley, J., & Plunkett, C. (2002). Women and domestic violence: Standards for counselling practice. St Kilda, Australia: Salvation Army Crisis Service.

Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48(2), 98-106. doi:10.1037/pro0000106

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