Section 3: Safety Planning and Referral

Where risk is present, it may be more appropriate for safety planning to be carried out by a specialist professional (e.g., a mental health clinician or suicide prevention specialist in the case of suicide risk or a DFV specialist service in the case of DFV risk). However, it is important that counsellors have the knowledge and skills to assist clients in developing plans that enhance their safety. For instance, if the client is not at sufficient risk to require immediate specialist help and instead has an appointment with a specialist in two days, you might work with them to develop a plan, including a commitment to seek emergency help if things get worse in the meantime. Again, it is important that you do so with the knowledge and oversight of your manager or supervisor.

Working from a Collaborative Approach

As you have learned in previous sections, achieving a balance between a collaborative and directive approach is a vital consideration when working with clients in crisis. Supporting clients to make informed choices about safety strategies and referrals, where safe and possible, is not only an ethical obligation of counsellors but also important so that clients feel empowered in situations where they often feel ‘out of control’.

The key to collaborative work is to draw out the client’s own knowledge, ideas, interests, preferences, and values. While you might provide information, prompt the client with questions and options, and offer tentative suggestions, you must recognise that it is the client who has the knowledge required for effective safety planning. It is quite normal to feel the urge to problem-solve and direct the client to what you think will be helpful, but you need to resist this urge and focus on supporting the client to make informed choices about the strategies that will work best for them. You will be aware of a range of healthy coping strategies, for example, but you will not know which of these will be most useful to a particular client when they are in a crisis situation. You must strike the right balance: provide solid support for the client and help generate ideas without taking over, as well as facilitate the client’s choice of strategies without leaving them feeling alone or unsupported in their efforts. Remember, an effective safety plan is one that the client owns.

In addition, safety plans must be tailored to client needs and made with the active involvement of the client. For instance, safety planning for a client subjected to DFV will differ according to whether or not the client is still living or in contact with the person using violence, and, if they are still co-habiting or in significant contact, whether or not they are planning to leave or end contact. Clients who are still in contact with the person using violence will require strategies (e.g., planning exit routes) for when the person using violence is present; whereas clients who have left the DFV relationships may need to consider how they can maintain safety (e.g., limiting knowledge of their location).

Strengthening Links to Safety and Living

An important aspect of safety planning involves acknowledging and reinforcing the client’s links to life and safety. As previously mentioned, you should note any protective factors as you listen to the client’s story, so that they can be further discussed and incorporated into safety planning. Protective factors will vary from person to person, but there are several common types (CARMHA, 2007; Reeves, 2015; Sommers-Flanagan & Shaw, 2017), including:

• social support, positive relationships, a sense of belonging, and community involvement
• reasons for living (for example, relationships, work, interests, values or beliefs)
• a sense of, and hopes for the future
• skills and capacities, including problem-solving, relationships, and coping skills
• cognitive factors such as an optimistic perspective
• fears associated with pain and death.

As you can imagine, active listening skills, questioning skills, and a strengths-based approach are vital here. Affirm and strengthen the client’s links to safety and living using appropriate counselling skills. For example, you might highlight their sense of hope for the future (e.g., a statement they have made about their desired future) and the skills they have demonstrated in the past to overcome challenges. This often links naturally into safety planning discussions where you and the client work together to identify possible actions to reduce their risk.

If a client is struggling to find reasons for living or things that they appreciate, try using your skills in exploring strengths and resources. You might have information from your discussion that indicates various links to life, which can be explored further. You can also acknowledge their attendance at counselling as a strength and as an indication of their desire to continue living and seek further strengths, resources, and links from there.

However, if the client is unable to identify reasons for living (or other protective factors) this indicates elevated risk (Corey, Corey & Corey, 2017) and you will need to consider adjusting your response accordingly.

Developing a Safety Plan

For a safety plan to be effective, it must be useful to the client and meet their particular needs, so while there are aspects important to all plans, the details vary. Generally, a safety plan will include a list of warning signs that indicate the client should start to work through the various strategy and support options listed in the plan. Your organisation may have a preferred format, but whatever format you use, ensure that it covers all the essential components of safety planning and is user-friendly. Safety plans need to be clear, concise, and easy for the client to understand in the midst of a crisis situation, when they may have difficulty with thought and concentration.

Providing a Client-Centered Referral

This role-play demonstrates one way of providing a client-centered referral.

The purpose of safety planning is to develop a document that guides the client in safety-enhancing actions when they are in the midst of a crisis of suicidality (they can also be of use in other situations of distress). The plan is aimed at either resolving the crisis or connecting with emergency or crisis care.

Check your understanding of the content so far!

Using the SPI template as a guide, let’s explore the following 7 steps involved in developing a safety plan.

Step 1: Warning Signs

Warning signs are indications that the client’s risk may be increasing or that a crisis situation is developing. The aim is to have warning signs specific to the individual client clearly listed on the safety plan so they can be identified by the client, family, or other supporters. Warning signs will differ depending on the particular client, and some may have already been identified in the risk assessment process. You may facilitate the identification of warning signs by asking a broad question, such as 'What sort of things might tell you that it’s time to start using the plan?'or focus on particular aspects that could indicate increasing risk. For example, when working with a client at risk of suicide, you may focus on warning signs such as:

• Thoughts and patterns of thought, e.g., 'Have you noticed any particular thoughts happening before or as you started feeling suicidal that could tell you that it’s time to use the safety plan?'
• Feelings and mood, e.g., 'What is the difference in your feelings or mood between when you are safe and when things are becoming unsafe?'
• Behavioural changes, e.g., 'Do you notice any changes in your habits that could indicate to you or [support person/family member/partner/friend] that a crisis might be coming?'
• Triggering situations, e.g., 'Do these thoughts/urges/feelings seem to be more likely at particular times or places, or in particular circumstances?'

Remember, be as clear and specific as possible, and write the plan in a way that makes it user-friendly. For instance, writing ‘anxiety’ on the plan is not as useful as listing specific experiences relevant to the client’s particular experience of anxiety (e.g., ‘trembling’, ‘racing thoughts’, ‘negative thinking, and ‘feeling sick to the stomach’). Be practical and keep in mind that they will likely be in a state of crisis when they need to use the plan.

Step 2: Coping Strategies

Coping strategies can refer to any safe (i.e., healthy or neutral) activities that the client can engage in to reduce risk. Again, these must be relevant and specific to the individual client. You will need to help clients figure out what will be useful for them, with reference to their preferences and circumstances. It is useful to take a strength-based approach and focus on what the client already does that helps them stay safe and keeps them alive. Where necessary, you may make suggestions based on your understanding of the client, but make sure that you check with the client if they are likely to use these strategies.

Encourage clients to identify coping activities that they have the resources for, and which will be easy to implement. For example, seeing a movie might be an effective distraction from suicidal thoughts, but if the client cannot get quick and safe transport to the movies, or cannot afford the fare, listing such a strategy could be counterproductive. It is useful to check in with the client regarding any potential barriers that might get in their way of using a particular strategy and find ways of reducing barriers where possible. You can also help the client visualise the steps they will take in order to engage the strategy. For example, in order to exercise, the client will likely need to decide where, when, and how they will exercise, buy or gather their gear, and so on.

When working with clients affected by DFV, this step of safety planning, and the ones that follow, may require discussion over strategies that clients can implement in different circumstances. You will need to engage the client in considering where the risks lie and what their priorities are, according to their particular situation. A client who is living with the person using violence needs a plan that responds to this, considering safety in the home and an escape plan if they need to leave either temporarily or permanently. A client who shares parenting responsibilities with the person using DFV requires a plan that includes strategies to support their own and their children’s safety despite ongoing contact. A client who has been tracked or stalked by the person using violence needs a plan that targets the tracking strategies employed; and so on.

Where applicable, you may also help clients develop age-appropriate safety strategies for child/ren (or others) who are affected, for example, in a DFV situation. It is recommended that you build upon the client’s strengths and acknowledge what the client is already doing to protect the child/ren (or others).

Step 3: People and Social Settings

Work with the client to identify at least two people they can connect with to get the benefits of social contact. These do not need to be people to whom the client will disclose their thoughts, feelings, or safety concerns (although they might be); what matters here is identifying people the client can connect with socially (e.g., have a chat, play games, exercise, or go out with) and who will help them feel better. You can ask the client directly whom they might find it helpful to connect with and whom they would be willing to connect with; who makes them laugh and who they feel better for having spoken to or spent time with.

The client is also asked about places they can go when they are unsafe. These may include the home of a friend, family member, or other support person; a public place, such as a café, library, or park where other people will be present; or a group or worship setting. It is important to check with the client regarding safety in these places. For example, listing a place where the person has previously made a suicide attempt or where they will have the means to carry out a suicide plan is clearly inappropriate and unsafe. Similarly, it is not advisable to list places that are isolated or not frequented by other people (note the safety plan refers to ‘social settings’, not just ‘settings’), or where alcohol or other drugs are present. It is also important to check whether the client can quickly and safely attend the place, how they would get there, and whether they would be likely to go there when in a distressed state.

Step 4: Support People

While support people are among the client’s social contacts, here we want to identify those people within the client’s natural support network whom the client believes will be supportive, helpful, and safety-enhancing. In listing these people on their plan, the client commits to contacting these people and telling them of the safety risk if they have identified warning signs or believe themselves to be unsafe for any other reason. Again, check in regarding safety and practicality; do not include people who are unsupportive, associated with increasing risk, or who might otherwise worsen the situation. For example, a person the client would confide in but who encourages the client to drink or use other drugs would not be an appropriate support person.

It is also important to check in with the client concerning the likelihood that they will tell the person what is going on or that they need help. A client may have a very supportive parent, partner, or friend, for example, but if they are not willing to tell that person when they are in a risky or distressed state, that person’s inclusion in this part of the plan is questionable. There are many reasons a person experiencing a crisis might not tell a support person, including worry about burdening them. Help the client consider practical barriers, too, including:

• how they will make contact
• when the person is likely to be available and unavailable
• whether the person is physically proximate and how the contact will occur
• what the client will do if the support person is not available.

Step 5: Professionals and Services

Safety plans must include a 24-hour crisis helpline (e.g., suicide prevention helpline; DVConnect, 1800 RESPECT), as well as both the local crisis assessment and treatment teams (CATT) and hospital. These are services for the client to contact if taking the previous steps has not resolved the crisis or at any time, they think such support to be their best or safest option. Remember that crises may develop at any point, so services available outside of business hours must be included.

Healthcare professionals and specialist support providers may include doctors, psychologists, social workers, psychiatrists, specialist mental health services, crisis intervention workers, and so on. Hotlines included must be appropriate for the client’s needs and situations. For example:

• LifeLine has a 24-hour crisis support hotline staffed by volunteers (13 11 14); it also has a text-based service option and online chat option during limited hours.
• Suicide Call Back Service (1300 659 467) provides 24-hour telephone as well as online counselling for people affected by suicide, including those experiencing suicidal thoughts or other suicide-related risks; supporters of people at risk of, or who have attempted, suicide; and people bereaved as a result of suicide.
• BeyondBlue operates a 24-hour hotline (1300 22 4636), as well as online chats during limited hours.
• DV Connect (1800 811 811) is a 24-hour domestic violence helpline that offers specialist trauma counselling as well as information and referral services. They also operate a Pets in Crisis Program to help arrange care for pets of families experiencing DFV.
• 1800RESPECT (1800 737 732) is another 24-hour hotline that offers information, counselling and support to people affected by sexual assault and/or DFV issues, including workers and professionals supporting someone experiencing, or at risk of experiencing violence.

Important note: The information provided is correct at the time of publication but may be subject to change; check the contact information for all services by accessing the respective services’ websites before providing information to clients.

Again, check in with the client about their willingness to contact these services when in distress, and how they will go about making contact. In listing these services, the client commits to making contact with them if previous steps have not resolved the crisis, and to attending a hospital if risk is imminent, or if other supports are unavailable or insufficient to their needs. Remind the client that they can also present to a hospital emergency department at any point if they need urgent assistance.

Step 6: Making the Environment Safer

The actions identified here need to enhance the person's safety. This often includes having a support person stay with the client, going to a safe person’s home, and preventing the use of alcohol and other drugs. The precise steps vary and should, as usual, be tailored to the client and their particular situation.

For example, in the case that a client has acknowledged a suicide plan, you will have asked for details of that plan, including the means involved; you will also have asked for details of any previous attempts and identified any means used during them. Given that the presence of a plan indicates elevated risk, such clients should be linked to specialist services. However, if you are in a position where you need to do a safety plan with such a client, making the environment safer will likely involve removing the means involved in any suicide plans or previous attempts. This may mean, for example:

• removing ropes and other items that can be used for hanging
• removing or preventing access to excess medications– a family member may keep the medication in a secure location, for example, or a ‘Webster pack’ may be arranged with the dispensing chemist (Webster packs typically include one week’s worth of medication only)
• removing or preventing access to firearms
• removing or preventing access to cutting implements (knives, and razors).

(If plans or previous attempts indicate other means of suicide, making the environment safer must adapt to this, with steps the client and/or supporters will take to reduce access clearly stated.)

On the other hand, making the environment safer for a person at risk of homelessness may mean discussing options for temporary accommodation, or what they can do to improve safety when they are spending the night in a car, for example. As for clients affected by DFV, this step will vary depending on their situation. It could mean strategies that a client can use to protect themselves when the person using violence is present or, for a client who has left the relationship, strategies to prevent their location from being discovered by the person.

Step 7: Reasons for Living

During risk assessment, clients may have identified reasons for living or things that are worth living for. To help them identify reasons for living to include in their safety plan, you could reflect on what you have gleaned about the client’s life and what matters to them through the course of your work, or ask more detailed questions about beliefs and values, relationships, areas of interest, things that they hope to see happen, and roles and meaningful activities they engage in (e.g., parenting, caring for, or supporting others; work – paid or voluntary; advocating for causes or supporting charities). Remember, if a suicidal client cannot identify supports or reasons for living, this can indicate that the assessed risk level be escalated and appropriate action taken (Corey et al., 2017).

When they have identified reasons for living, help the client find ways to remind themselves of these things, such as making a list and putting it somewhere they will see it, gathering objects that serve as reminders and putting up pictures. The client can also be encouraged to consider how they might work more activities that are meaningful, or which relate to their values or beliefs, into their lives. As with pleasant activities, a multitude of different, positive acts could be relevant here. Just a few include taking a few moments for prayer, reflection, or gratitude; making contact with a loved one or letting someone know the client is thinking of them; signing a petition or adding a letter to a campaign; creating art; and engaging in activities to promote good health.

Check your understanding of the content so far!

Remember!

Safety plans need to be actionable when the client is in a highly distressed state, so they must be very clear and simple. The actions included must be both relevant and practicable. The client is asked to commit to working through the safety plan any time they identify warning signs or otherwise believe themselves to be at risk (although they may also use aspects of the plan when distressed for other reasons). This is a commitment, and the commitment includes contacting crisis care – e.g., the CATT or hospital – if working through the previous steps has not returned them to a safe state. This table might help you remember critical points for safety planning:

Do's

Don'ts

Listen for warning signs, coping strategies, supporters, and protective factors throughout client contact, and engage the client in reflecting on these when safety planning. View the client as the expert in their own experience, and the person with the most knowledge about what does and does not affect them. Help the client use their own ideas and knowledge, and think through what is likely to be useful, relevant, and helpful in keeping them safe. Check in concerning each element of the plan: Is it relevant to the client? Is it actionable? Are there barriers that need to be considered? Does the client have the resources to take each step? Adapt the plan as required in response to feedback.

Do not rush the process. Do not develop the plan yourself. Do not encourage the inclusion of warning signs without critically considering whether they are relevant to the client and clear enough to be understood while the client is distressed. Do not encourage the inclusion of coping strategies or other action steps without critically considering whether they are likely to be useful, are clear enough to be understood while the client is distressed, and are actionable (i.e., that there are not significant barriers to their being enacted). Do not make assumptions about warning signs. Do not make assumptions about what will help the client enhance their safety.

Now, let’s look at a case study where safety planning is carried out with a client at lower risk of suicide.

Robin’s Safety Plan
Step 1:	Warning signs
Thoughts about death, particularly thoughts about myself dying Being at home alone and not being able to sleep Feeling like I’m going to throw up
Step 2:	Internal coping strategies
Watch a light-hearted TV show Do some baking Play with Spots
Step 3:	People and social settings that provide distraction
Name: Ursula : Phone: 0000 000 000 Name: Marian : Phone: 1111 111 111 Place: Library (daytime) Place: Gamer Café (24-hours)
Step 4:	People I will ask for help
Name: Penny: Phone: 2222 222 222 Name: Mackayla: Phone: 3333 333 333 Name: George: Phone: 4444 444 444
Step 5:	Professionals or services I can contact during a crisis
Name: Dr Sanderson: (GP) Phone: 55 5555 5555 Name: Central City Women’s Health Service: Phone: 66 6666 6666 Crisis assessment and treatment team: Mental Health Crisis Line 7777 777 777 Suicide prevention hotline: Suicide Crisis Line 8888 888 888 Hospital: NSW General Hospital – 2 Main St – 99 9999 9999
Step 6:	Making the environment safe
No alcohol in the house Go to Mackayla’s or George’s/call Mackayla or Penny to come over
Step 7:	Reasons for living – The things that are most important to me and worth living for are:
Family, especially Mackayla, George, and Penny (and Spots!) To see Mackayla, get married one day Trip to Fiji and New Zealand in January Things I love to do! Hiking, surfing, reading, choir, playing with Spots… Friends like Ivy, Rina, Steve, Ursula, Marian Getting to do work that helps people

It is also important to remind clients that the plan is not set in stone. Like risk assessments, they should be reviewed and updated as appropriate, and reviewing safety plans regularly in session is important. A client’s plan might be updated as they identify different warning signs, learn new skills, develop further supports, or realise that some aspect of it is impractical.

Reducing Immediate Risk

In addition to developing a safety plan, other actions may enhance the client’s safety, such as involving support people and taking immediate steps to make the client’s environment safer. You may be required to contact emergency or crisis services, or other appropriate professionals, but even if this is not necessary, further action for immediate safety is important.

The involvement of family members or other natural supports is recommended, and you should discuss this with the client. You might facilitate this through planning how the client will contact a support person or people and what the client will tell them, or through contacting a support person in collaboration with the client. For example, if you are meeting with a client and have identified a potential suicide risk, you might jointly call the client’s parent, sibling, partner, or other supporter; you can then support the client in informing the support person of the nature of the situation and talk about how the client and their support people can enhance the client’s safety. You might be in a position to meet jointly with the client and a support person or people (for example, if a family member has transported the client to the session or lives/works locally); or, if you become aware of the risk during telephone or video contact with the client, the client might invite a support person to come in on the call. As always, you need to maintain confidentiality and only discuss client-related information with the client’s consent, unless legal and ethical justification for information sharing applies.

You should also guide the client through considering practicalities and further support. If the decision made, in collaboration with the client and your manager/supervisor, is that emergency or crisis care is not required, there will be a number of items to review. For example:

• Where will the client go when they leave the session? Will they have support there? If the client is planning to go home alone, this is naturally concerning and may lead to further consideration of whether other actions are required, such as making contact with an appropriate support option.
• Does the client require additional support to take steps to enhance their safety? What social and professional supports are available? How will the client contact these supports?
• Who else will be involved in ongoing service delivery? How will they be involved?
• When will you (or your manager) follow up with the client? When will you check in regarding the implementation of steps to enhance safety? What else will your service do to help enhance the client’s safety?

Regardless of whether a client is facing a crisis, a referral is appropriate whenever a counsellor recognises needs that are beyond their professional role or expertise. The steps involved in supporting the client and making a referral can differ based on the client’s capacity and the severity of the risk or crisis. For instance, facilitating access to emergency services may be vital to clients at high risk, but not necessary for a client who is relatively safe and competent to access services.

Identifying Referral Options

Clients’ needs and situations vary greatly, so the referrals that will be appropriate vary too. As such, it is important that you work collaboratively with clients to identify the most appropriate support services for them. Services and professionals that counsellors may refer clients to include:

• Medical professionals and services, such as general practitioners (GPs) and psychologists. These professionals can offer assistance to clients for managing physical and psychological symptoms, and conduct comprehensive assessments of physical, developmental, and mental health.
• Mental health professionals and services, such as psychologists, mental health social workers, and community services with mental health programs.
• Alcohol and other drug services to assist clients experiencing AOD issues.
• Public, emergency, and statutory services, such as state/territory police, including local stations, DFV and child protection teams; state/territory child welfare authority; state/territory victim assistance program; probation and parole; and other justice-related services.
• Crisis response services, such as crisis assessment and treatment teams, and programs that help clients respond to particular crises (crises of suicide, severe self-injury, trauma, disaster or violence).
• Emergency relief services, for example,financial counsellors can help clients with consolidating debts, negotiating debt relief or repayment terms, and budgeting skills. However, where emergency relief is required in times of crisis, clients in financial distress can be referred to community services that offer financial relief, food relief, and emergency aid. These services usually offer one-off assistance through various means such as food vouchers, transport vouchers, clothing, or part-payment of utility bills.
• Child and parenting services, such as children’s counselling services, issue-specific programs (e.g., Supporting Children After Separation Program), children’s contact services (supervised contact with a non-resident parent where safety concerns are present), parenting programs, and the child welfare authority in your state/territory.
• Housing and accommodation services, including emergency accommodation, social housing programs, the public housing authority in your state/territory, and community-based programs to help people find and maintain tenancies.
• Legal services, such as the Legal Aid Commission in each state/territory, community legal centres, women’s legal services, and ombudsman systems that can address issues of unfairness and unlawful conduct (such as FairWork Australia, industry ombudsman, etc.).

For example, when supporting a client affected by DFV issues, one of your most valuable resources will be your local DFV-specific community service. The particular programs offered will differ, but these services regularly provide comprehensive and specialised information, referral, risk assessment, and safety planning services, often over the phone. They may have case management programs, facilitate service delivery, provide advocacy, and assist clients in completing important documents. Many offer specialist individual and group counselling, and some have specialised children’s counselling or group programs. In addition, such services often provide brokerage for safety upgrades, assistance in relocating, or emergency relief (e.g., providing food, toiletries, or vouchers for clients in financial hardship). DFV services often work with other professionals, and provide information and suggestions for workers who have clients impacted by DFV.

It is recommended that you develop a comprehensive referral directory that contains the details of local referral sources so that you can use this during client contact and follow-up. You will need to make sure that the information in the directory remains up-to-date.

While it is more common for clients to be referred externally to other local support services or professionals, internal referral (for example, referring a client to another staff member or program within your organisation) can be appropriate at times. This is more likely to happen when counsellors work in a multi-program organisation or within a multi-disciplinary team. Imagine you are working with a parent who has concerns about their child’s mental health; you may be able to organise a referral to a children’s counselling service in your organisation, to a family therapist on your team, or to a parent support program run by a co-worker. Where a client’s issues and needs are beyond the scope of your training and experience, it may also be appropriate to refer the client to a co-worker who has more expertise in that area. As with most circumstances relating to serious client issues, it is important to consult with your manager or supervisor.

Assessing Referral Options

Referring always needs to be done with sensitivity. When working with clients who are at risk or otherwise in crisis, this is all the more important. Given the extreme stress that such clients are under, being turned away from a service because it is not suitable, or being referred to a service that fails to meet their needs, can be extremely distressing and can lead to increased safety concerns. When considering possible supports, it can be helpful for the counsellor to consider practical questions, such as:

• Can the service help the client meet their needs?
• Are there specific criteria clients must meet in order to be eligible to access the service? If so, does the client meet these criteria?
• Is the service local and easily accessed by the client? (For example, if the client does not drive, will they be able to access the service by public transport or can someone from the service visit the client in an outreach capacity?)
• Are there fees associated with accessing the service? If so, can the client afford them, can you advocate for the fees to be reduced or waived, or can financial support to cover the fees be sourced?

Provided that the risk is not so high or imminent as to require emergency intervention, you will need to gently discuss referral options with the client and help them make decisions. You need to provide sufficient information for the client to make informed choices, and take the client’s particular needs and circumstances into account. If there are a number of viable options, you will need to help the client think through the pros and cons involved. You can assist this process by providing a brief description of each option in turn, exploring whether and how each could improve the client’s situation, and answering any questions the client has. This, too, needs to be handled patiently and sensitively: the client may be vulnerable to feeling rushed, overwhelmed, or stressed if you do not facilitate the decision-making process carefully.

Facilitating the Referral Process

Wherever possible, referrals should be made in a way that promotes client autonomy and supports clients in regaining a sense of control. Counsellors should not be making decisions on behalf of the client; rather, the counsellor and client should work collaboratively.

Counsellors need to be careful how they encourage clients to contact services. For example, telling a client they must do something can often be met with resistance, and is too directive. Instead, James and Gilliland (2017) emphasise the importance of facilitating as much client input as possible, because “the best alternatives are ones that the client truly owns” (p. 92). They suggest using open-ended questions to prompt the client into providing ideas about the kinds of services that might be helpful to them, with the counsellor adding their ideas to the list and using their knowledge of referral options to help match services to the client’s needs.

The counsellor and client should also work together to make plans for how the referral will proceed. When the client has determined their preferred option, they can be supported to contact the service themselves (potentially with the counsellor present) or the counsellor can make a warm referral (contacting the service on the client’s behalf). The following extract provides an example of working collaboratively to make referral plans.

Rita:	Right now, I’d like to just be free of the whole mess for a few days… just get off this dizzy merry-go-round long enough to collect my thoughts.
Counsellor:	It sounds to me like you really mean that. Let’s see if together we can examine some options that might get you the freedom and breathing space you need to pull the pieces back together.
Rita:	I can’t really let go. Too many people are depending on me. That’s just wishful thinking. But it would be wonderful to get some relief.
Counsellor:	Even though you don’t see any way to get it, what you want is some space for yourself right now – away from work, kids, Jake, Sam, and the whole dilemma.
Rita:	The only way that would happen is for my doctor to order it – to prescribe it, medically.
Counsellor:	How realistic is that? How would that help you?
Rita:	It would call a halt to some of the pressures. The treadmill would have to stop, at least temporarily. Yes, I guess that kind of medical reason wouldn’t be so bad.
Counsellor:	Sounds like consulting your doctor and laying at least part of your cards on the table might be one step toward getting medical help in carving out some breathing space for yourself.
Rita:	I think so. Yeah, that’s it! That’s one thing I could do.
Counsellor:	Let’s together map out a possible action plan – for contacting your doctor and requesting assistance in temporarily letting go. Let’s look at when you want to contact your doctor, what you’re going to say, and how you’re going to say it – to help you get the result you want. (Adapted from James & Gilliland, 2017, p. 93)

It is also important to obtain a commitment to follow through. James and Gilliland (2017) suggest asking the client to verbally summarise the steps in order to ensure that they have understood the actions to be taken. This also allows the counsellor to clarify any misunderstandings.

Counsellor:	So, Rita, it seems to me that what you’ve decided to do is to reinitiate some kind of meaningful contact with Mr. Jackson. So that we’re both very clear on what you’ve committed yourself to doing, would you please summarize how and when you’re going to proceed?
Rita:	I’m going straight to my office today and will phone him at school. I’ll either talk to him or leave a message for him to call me. As soon as I talk to him, I’ll set up a definite day and time to meet with him.
Counsellor:	And when you’ve set up…
Rita:	Oh, yes! And when I’ve set up my appointment with him, I’m going to phone you and let you know how it went. (Adapted from James & Gilliland, 2017, p. 94)

You may remember learning about different types of referrals in CHCMHS001 – Work with people with mental health issues. Referral processes vary from providing the client with service information and leaving them to contact the service (a cold referral) to arranging the other service and attending with the client. Different methods all have their place, but perhaps the most frequently useful when you have concerns about client safety or suitability will be a particular type of active, warm referral: a conversation between the client (on the phone or in person), counsellor, and referral agency.

For instance, during a session, the counsellor might call the referral agency; introduce the client; explain why the client requires a referral; and help the client provide background information relevant to the referral. This has the benefit of enhancing client involvement in the process and allowing greater transparency than when a referral conversation takes place between the counsellor and referral agency alone. This also allows the client to clarify any concerns they may have about the services, thereby reducing one common barrier to accepting help. However, as referral procedures and preferences differ between organisations and services, and warm referral may not be acceptable in some contexts you will need to be:

• familiar with relevant policies and procedures in your workplace
• familiar with the preferences of the agency receiving the referral
• skilled in arranging other types of referrals.

In addition to considering the needs of the client, the counsellor also needs to consider other people who may be at risk, such as the client’s children, family members, or carers. Where others are in immediate danger, counsellors also have a duty of care to work towards reducing risks to them. This duty can override the client’s right to confidentiality, such as when a counsellor needs to contact appropriate authorities (e.g., police or child protection authority) to protect safety and prevent harm. As you will have come to expect, in such situations it is important for the counsellor to consider their legal and ethical responsibilities, their organisation’s policies and procedures, and to seek out the assistance of their supervisor or manager.

There are also situations where counsellors will need to take a more directive approach, such as when a client is at high risk or is in crisis and has limited capacity to access support themselves. In these cases, a counsellor has a duty of care to contact appropriate clinical, crisis, or emergency services. Cautious and sensitive judgement, and consultation with your supervisor or manager, are important when deciding whether this is necessary.

Facilitating Access to Emergency Services

You may need to contact emergency services, such as ambulance or police when there are serious safety concerns. Where possible, encourage the client to make contact and provide support for that to happen. Nonetheless, at times you may need to exercise your duty of care and contact emergency services yourself, even without client consent.

When contacting an emergency service, ensure you have relevant information at the ready. Remember that you only have the right to share what information is necessary to enable the service to do its job or that the client has consented to your sharing. When you call the emergency number (000), you will be asked whether you require police, fire, or ambulance. Provide this information, and you will be transferred to a dispatch officer. You will then be asked for specific information, such as where the emergency is, the nature of the emergency, the name and date of birth of the person concerned, and whether the person is conscious and breathing. If there is something you do not know, accept that they need to ask and calmly say that you do not know. You may need to stay on the phone until help arrives. Regardless of any stress you might feel in such a situation, it is your responsibility to behave in a patient, professional manner. As you may imagine, having additional staff (ideally management) present while you do this is extremely helpful.

In addition to attending emergency situations, police and ambulance services have the capacity to carry out welfare checks, in which they attend the home or known location of a person considered to be at risk, to check on their welfare and offer assistance. For instance, you can report a suicide risk concern and request a welfare check from your state or territory police or ambulance service, provided you have legal and ethical justification for sharing client information. Again, this is best done with the oversight of your manager or supervisor.

Referring the Client to Crisis Services

Each state and territory has crisis assessment and treatment teams (CATT), although these are known by different terms in various parts of the country. They are usually contacted via telephone. The service names and phone numbers are provided in the following table (HealthDirect, 2019). However, details can change, so check the relevant service for your state/territory regularly.

State/territory	Name for CATT	Contact method
ACT	Crisis Assessment and Treatment Teams	Mental Health Triage Service – 1800 629 354
NSW	Acute Care Teams	Mental Health Line – 1800 011 511
Northern Territory	Crisis Assessment and Treatment Teams	Northern Territory Crisis Assessment Telephone Triage Service – 1800 682 288
Queensland	Acute Care Teams	1300 MH CALL – 1300 64 22 55
South Australia	Mental Health Triage Service	Mental Health Triage Service – 13 14 65
Tasmania	Crisis Assessment and Treatment Teams	Mental Health Services Helpline – 1800 332 388.
Victoria	Acute Community Intervention Service	See http://www.health.vic.gov.au/mentalhealthservices/ Note: The contact number for psychiatric triage varies depending on service areas. Make sure that you check the number for your region.
Western Australia	Mental Health Emergency Response Line	Mental Health Emergency Response Line – 1800 676 822

CATTs can enhance safety and connect clients with appropriate services, including assessing whether hospitalisation is required. Some will also work collaboratively with other service providers, including helping professionals. This may be appropriate if a client requires specialist crisis intervention – such as support to reduce suicide risk, or mental health assessment and intervention – but where they may not need an ambulance or police response. Having discussed the service with the client and gained their consent, you may contact the local CATT to find out whether they can assist the client. Unfortunately, public mental health crisis services such as the CATTs can be understaffed relative to demand. If the team is unable to attend immediately, you will need to take action to ensure another appropriate service, such as an ambulance service, is engaged.

If the client is at high and/or imminent risk and you have not arranged and overseen their transfer to the appropriate emergency or clinical care (either police, ambulance, CATT, or other psychiatric care), you will not have discharged your duty of care. This is a serious professional and ethical breach, and can also result in legal issues. You are responsible not only for referring the client to crisis care but also for overseeing their transfer into the care of an appropriate service. If you have reasonable grounds for believing the risk to be sufficiently high, but the client is not physically present (e.g., if the client leaves or if contact is via phone, text, or internet), contact the police immediately, report your concerns, and request a welfare check. As always, seeking advice or assistance from your manager/supervisor can be extremely helpful in these cases for your own well-being as well as to make sure that you are acting in accordance with your organisational policy and procedures.

Addressing Barriers to Support

Some clients may show reluctance or ambivalence when it comes to using other services or accepting referrals. While you may think a referral is for the best, the client may not agree with you. Where appropriate, explore the reasons behind their reluctance and try to address any barriers to accepting referrals. There are a range of factors that can affect a client’s willingness or capacity to accept and act on a referral, many of which can be effectively addressed, including:

• misinformation and/or lack of understanding
• previous negative experiences
• logistical issues
• personal beliefs and values about seeking help
• concerns about safety
• lack of motivation.

Misinformation and/or lack of understanding

It is important to provide the client with details about the relevant service(s) (while not overwhelming them with information) to help them make informed decisions about whether the service(s) is/are likely to be useful to them. Always check a client’s understanding; clarify misunderstandings; and, where possible, provide service information in the client’s preferred language.

Previous negative experiences

These may be their own or another person’s experience and can result in anxiety about or disbelief in the benefits of engaging with support services (either in general or in relation to one service or service type in particular).

Logistical issues

Clients may refuse or be unable to act on referrals if they lack resources. For instance, they may not be able to pay the fees involved, may have limited access to transport, or may lack childcare support that would allow them to attend appointments.

Personal beliefs and values about seeking help

Clients may believe that seeking help is a ‘cowardly’ or ‘unmanly’ act. They may also worry about being judged by community members if they access mental health services, being identified and dishonoured as a victim if they access sexual or domestic violence services, and so on.

Concerns about safety

A client who has been experiencing DFV may be concerned about their safety (e.g., being located by the person using violence) and worry that they may be in a worse situation if they were found to be accessing support services. This is one of the situations in which the importance of understanding and respecting client reluctance is very clear; after all, it may well be the case that the perpetrator discovering their service use could further endanger the client.

Lack of motivation

A client may lack the motivation to seek further help due to overwhelming feelings, exhaustion, or the symptoms of a mental illness.

Empathy and active listening skills are vital in exploring barriers to seeking or accepting help. While it can be frustrating to you as a counsellor, taking time to explore a client’s underlying reasons is a good demonstration of positive, client-centred helping; it also promotes client autonomy and empowerment, supporting the client to make informed choices. It is always good practice to check the client’s understanding of referral information and to consider the client’s opinions and feelings about particular referral options.

Where a client has difficulties or challenges in accessing services, you may work with them to identify alternatives or ways to overcome these barriers. For instance, if the client requires childcare when attending appointments, you may explore possible options and the resources they have. This can involve taking on case management responsibilities, such as linking clients with additional resources to help address issues or advocating for a client to receive a particular service, reduction in charge, transport or child-care assistance to facilitate their service access.

It is also common for clients to feel reluctant about being referred to other professionals because they do not want to have to retell their stories or develop a relationship with another worker after opening up to the counsellor. They may also feel that further support should not be necessary. In such cases, the counsellor needs to help the client understand the reason the referral is being suggested and provide sufficient information about what to expect if it goes ahead to help reassure the client. The counsellor should also explain the limitations of the counselling services provided. For example, you might outline the scope of your practice role and its boundaries, as well as the benefits that additional support can provide. It can be useful to clearly explain what you can and can’t do, such as saying, 'What I can do is work with you and come up with some strategies to help you respond differently when this comes up. I won’t be able to actually help you find a job or redo your resume, so that’s why I’d like to look at what services nearby can help you with that.' Where appropriate, you might arrange to call the referral agency together with the client so they can ask questions about the service. You might also obtain the client’s consent to provide an overview of the relevant information to the agency so that the client does not have to retell their story in its entirety.

In most circumstances, it is ultimately the client’s decision as to whether they will accept and act upon the referral, and your responsibility remains in facilitating this process. If a client refuses to accept it, provide them with written information and contact details in case they change their mind. As mentioned, you may need to override client confidentiality and contact crisis services when a client is at high risk or has limited capacity to access support themselves. Once again, it is important that you always act in accordance with your organisational guidelines and consult your supervisor or manager. Any steps taken in referring your clients should be clearly documented in the client’s files.

Barriers to communication in counselling and psychotherapy

This video discusses types of barriers and how to overcome them.

Throughout your work with each client, it is important to develop and maintain documentation in accordance with your professional responsibilities and organisational standards. Documents that you will need to keep on each client’s file include:

• consent, intake and assessment forms
• records of any risks suspected or identified
• risk assessment documents
• referral forms and other communications with other workers and services
• any other client documentation, such as regular case notes, records of actions taken, and records of notifications to authorities.

Particularly when there are crisis or risk-related issues, you also need to document wherever you have screened for, suspected, identified, or assessed risk; conducted safety planning; and any action taken in response. You will also need to maintain copies of risk-related documents (such as completed screening, assessment, and safety plans) and details of communications with other services. You may also like to make the records related to risk assessment easily identifiable, by including an additional risk-related section in your notes format or using a different font or format for that risk-related notes.

For instance, if a client made a statement indicating possible suicidal thoughts and you asked the client whether they were considering suicide, you would need to note the client’s statement (ideally in the exact words they used) and their responses to your questions. You would also need to note any further action you took, such as additional discussion, risk assessment, and collaboration with your supervisor or manager. Apart from meeting your responsibilities regarding record keeping, such notes will also help you monitor and respond to client risk over time. For example, if the risk escalates or recurs, you will have a clear reminder of when the risk appeared previously, the results of any risk assessment, strategies that have helped in the past, and any potential resources.

Similarly, whenever a referral is made, counsellors must keep appropriate records. In most cases, you will need to obtain written consent from a client to contact another service or professional regarding a referral. In situations where the client faces imminent risk (e.g., high suicide risk) the counsellor may need to contact emergency services without client consent. In such cases, it is important for the counsellor to clearly document the concerns that led to them making the referral or report, any consultation that they engaged in, and the actions taken.

Before we conclude this section, let’s look at an approach to documenting risks, which can be integrated into regular session notes.

In this section of the module, you have learned about the critical considerations involved in safety planning and facilitating referral to appropriate support services. These are particularly important for supporting at-risk or in-crisis clients, as they often have immediate or ongoing needs that can escalate their situations. Particularly, counsellors need to be vigilant about working with clients in a way that is as collaborative as possible. However, be prepared to take more directive steps to fulfil your duty of care when clients at imminent risk are unable or unwilling to access support. 

Acknowledging the difficulties that may arise for counsellors when dealing with clients in crisis, the concluding section of this module will focus on self-care and support for counsellors.

Centre for Applied Research in Mental Health and Addiction. (2007). Working with the client who is suicidal: A tool for adult mental health and addiction services. Retrieved https://www.health.gov.bc.ca/library/publications/year/2007/MHA_WorkingWithSuicidalClient.pdf

Corey, G., Corey, M. S., & Corey, C. (2017). Issues and ethics in the helping professions (10th ed.). Boston, MA: Cengage Learning.

Healthdirect. (2019). CATT – the crisis assessment and treatment team. Retrieved from https://www.healthdirect.gov.au/crisis-management

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.

Pope, A. L., & Pow, A. M. (2017). Crisis management and disaster relief. In J. S. Young & C. S. Cashwell (eds.) Clinical mental health counselling: Elements of effective practice. Thousand Oaks, CA: Sage.

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

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