Suicide-risk protocol in psychology practice: response, referral and documentation

Working with suicide risk in psychology practice is not an exceptional scenario: any psychologist with an active caseload will face it sooner or later. Having a clear, rehearsed and documented protocol is what separates a professional response from an improvised one.

This guide outlines a professional protocol to assess risk, build a safety plan, decide on referral, document the intervention and look after the therapeutic team. It does not replace specific training (Linehan, Stanley-Brown Safety Plan, ASIST) but it serves as an operational backbone.

Risk assessment: what to ask

Asking directly does not increase risk: what increases risk is not asking and leaving the patient alone. Steps:

1. Ideation: thoughts of self-harm or not wanting to be here?
2. Plan: thought-out method, place, moment?
3. Means access: stockpiled medication, weapons, accessible heights.
4. Intent: would they do it if given the opportunity?
5. Protective factors: network, children, reasons to continue.
6. Risk factors: prior attempts, substance abuse, isolation, recent loss, chronic pain.

Critical combination: ideation + plan + means + intent → high risk requiring immediate action.

Safety plan: the key document

The safety plan (Stanley-Brown) is a brief document built with the patient, not for them. Structure:

1. Personal warning signs (what they notice before crisis).
2. Internal coping strategies (breathing, distraction, walking).
3. People and places that distract positively.
4. People to ask for help (with real phone numbers).
5. Professionals and emergency services (therapist, 024 in Spain, A&E).
6. Measures to limit access to lethal means.

When to refer to emergency and how to do it

Urgent referral when there is a structured plan, access to means and intent, or after a recent attempt. How:

• Don't leave the patient alone in the room.
• Call 112 or accompany to hospital emergency.
• Contact a family member or support person (with consent if possible; without it if life is at risk).
• If online: locate the address, contact local emergency services, keep the video call open until they arrive.
• In Spain: 024 (suicide helpline), 112 (emergency), 061 (health).

Professional secrecy yields when there is serious risk to life (COP code of ethics, art. 5).

Clinical record: what must be in writing

After a session involving suicide risk, log in the clinical record on the same day:

• Date, time and reason for the crisis intervention.
• Risk assessment (ideation, plan, means, intent, factors).
• Clinical decision taken and rationale.
• Signed safety plan (where applicable).
• Communications made (family, another professional, emergency).
• Next contact (24-72 h).

More in digital clinical history: if a claim arises, the only defence of your action is detailed documentation.

Between-session follow-up

• Brief call or message 24-48 h after crisis (not therapy, just containment and check-in).
• Temporarily increased session frequency (1-2 per week).
• Coordination with psychiatrist if pharmacological treatment is involved.
• Clear between-session communication agreement (channel and expected response).

Therapist and team self-care

Accompanying suicide risk is draining. Essential mechanisms:

• Clinical supervision with the live case.
• Immediate decompression spaces after session.
• Professional grief protocol if the patient dies.
• Cap on simultaneous high-risk cases in the schedule.

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