Lesson 6: Threats of Suicide, Homicide and Other Violent Acts



suicide note components mapped on the brain

Death is not the greatest loss in life. The greatest loss in life is what dies inside us while we live.
- Normal Cousins

Learning Outcomes

Upon successful completion of this lesson's material students will be able to:

  • Complete a risk assessment and what information to be mindful of when assessing crisis situations.
  • Describe the limitations to confidentiality as it relates to duty to warn.
  • Identify techniques and warning signs that indicate additional action may be warranted to prevent harm.


Suicidal Crises

Assessing Risk

    • Here are some tools developed to help mental health workers asses the risk of suicidality in individuals they are working with. Each agency will determine which method of assessment their staff will use. If the agency does not specify a tool then it is up to the mental health worker to determine the best assessment process for him or herself. There is a misconception that if you ask a person if they are thinking of killing themselves or you ask if you have a suicide plan, that this will plant an idea in the person's head. All of the research indicates that it does not increase a person's risk of suicide to inquire about suicidal thoughts or a suicide plan. In fact it reduces the risk because if someone has a plan they are more likely to talk about it when asked. If you don't ask they may not tell you.

    I am presenting a variety of suicide assessment options here:


    • Once you have assessed the risk then you can determine the next step.
    • It may be returning home and seeking mental health treatment.
    • It may having a full crisis assessment with a crisis worker.
    • It may be going to the emergency department of your local hospital to keep your client safe until they can be assessed and potentially hospitalized in a psychiatric hospital. Hospitalization is appropriate if the individual is assessed to be at significant risk of harm to themselves or harm to others.
    • Here is a list of questions you could ask about suicidal intent:
      • Are you currently thinking about or have you recently thought about death or harming yourself?
      • Have you thought about how you would harm yourself? What is your plan?
      • Do you have access to the method (e.g., gun and bullets, poison, pills)?
      • What has kept you from acting on these thoughts?
      • Do you have any intention of following through with the thoughts of self-harm?
      • What are your plans for the future?
      • Have you or a family member ever attempted suicide in the past?
      • Have you or a family member ever been diagnosed with or treated for anxiety, depression, or other mental health problems?
      • Are you currently using alcohol or drugs (illicit or prescription)?
      • Have there been any changes in your employment, social life, or family?
      • Do you have friends or family with whom you are close? Have you told them about these thoughts?
      • Do you tend to be impulsive with your decisions or behavior?


    • After initial stabilization and improvement of suicidal ideation, the individual remains at increased risk. Individuals who attempt suicide have a risk of death in the following year 100 times greater than that of the general population. Therefore, it is important to involve the person's social support system in assisting with management of the person's treatment. In addition to frequent contact with the primary care physician (PCP), the person should have access to behavioral health specialists, as well as community programs such as Alcoholics Anonymous or Narcotics Anonymous if substance abuse or dependence is involved.
    • For people with personality disorders, particularly borderline, histrionic, and narcissistic disorders, suicidal gestures and intent may become common and chronic in nature. The staff working with the person must be vigilant in taking each threat seriously, because gestures may become lethal. Some medical practice guideline suggests that physicians should assess regularly for suicide risk level and coping resources and help these individuals identify problem-solving techniques. If the person remains at a high risk of self-harm, referrals to emergency services and specialty care are recommended (from http://www.aafp.org/afp/2012/0315/p602.html).

Homicidal and Violent Crises

    • Defining
    • Statistics
    • Here is an example of a danger assessment tool to help a worker determine an individual's level of harm towards other: Danger_Assessment_Tool

Confidentiality and Duty to Warn

There are few more difficult events in life than the suicide of a loved one; especially if it is witnessed.  I simply cannot imagine the pain that would come from the death of a child, husband, wife, girlfriend, boyfriend, mother, father, grandmother, grandfather, cousin, aunt, uncle, or close friend at their own hands.  How does someone go on after that?  As most people who commit suicide do not leave notes, how do those left behind resolve the questions that will never be answered?  Perhaps this is one reason why those who have experienced a suicide of a loved one are statistically more likely to do so themselves at some point in their lives?  As days go on, we may start to think, "what did I miss?"  Some family members and close friends of those who commit suicide often do not resolve this unfounded guilt. As they are able to look back after the death, they may start to identify many of the signs they "missed." Part of their grief process includes the attempt to resolve the self-blame on top of the other challenges resulting from such a loss.  It becomes a crisis experience for many.

As future mental health professionals, it is imperative that you come to understand how suicidality is assessed and the mandatory reporting requirements that are incumbent upon you in those instances when someone is imminently suicidal.  As one of the few legal requirements that mandate the violation of confidentiality, clinicians must take steps to prevent an impending suicide.  In Maine, this process is called "Blue Papering" and "White Papering."  You will learn about the warning signs that someone is potentially suicidal. While these issues are not black and white, several questions should be asked to determine the risk level of the person that you are working with.

Another unspeakable act is the purposeful killing of someone else- especially the murder of one's own children and/or spouse/significant other.  As we have just finished the lesson on domestic violence, it is worth mentioning that homicide is often the end product of the cycle of violence.  As you are probably aware, the most common pattern is the murder of the children, the spouse and then, the suicide of the perpetrator. It is the ultimate act of control and domination.  Mental health professionals are also required to violate confidentiality if we assess that a potential homicide is imminent.  We must do so regardless of whether the intended victim is known or not.  In most states, not only do we need to notify the local authorities, we also are bound by what is termed the, "Duty to Warn" the intended victim.  Maine does not currently mandate this through law. However, be aware of the significance of the Tarasoff case.

In the 1970s, a young male student at the University of California at Berkeley sought help at the campus counseling center.  While in session with a clinician, he told the therapist that he intended to kill a young woman that he had been involved with romantically.  Sadly, he did end up killing the young lady (her last name was Tarasoff).  Soon thereafter, a successful civil law suit was brought by her family against the Regents of the University of California.  As a result, the "Duty to Warn" or "Tarasoff Ruling" was put into California state law.  Many other states enacted this law as well. In essence, this stipulates that, in addition to the required report to authorities, clinicians must make a reasonable attempt to obtain identifying information about any intended victim and immediately attempt to make contact and warn that individual.  While most cases of homicide are perpetrated against an identified victim, as we have so tragically witnessed in the media, this is not always the case.  The mass shootings perpetrated in the US (Columbine, Virginia Tech., Sandy Hook, etc), targeted victims completely at random.  While the vast majority of the mentally ill are not dangerous, there is a small subset which have these tendencies.  With the current laws and ethical standards mandating confidentiality in treatment, clinicians must carefully assess potential homicidality, and, within the bounds of state reporting laws, notify the authorities and, in many states, the intended victim.  The problem with these laws is twofold. First, the legal wording of when the reporting threshold is reached is often quite vague (i.e. reasonable suspicion, imminent, current, etc).  Given recent events, many states are now attempting to rework their statutes to allow providers to meet a less stringent threshold in order to violate the laws of confidentiality and trigger a report (New York was the first state. Those changes were made since the Sandy Hook massacre.).  The second major issue concerns potential lawsuits for the violation of confidentiality if the threshold is not clearly met.  Mental health providers can be sued and face state ethical charges should a report be made without clearly meeting the legal threshold.  Of course, the same can be said if the report is not made when it should have been. Clinicians are at risk of violating "Duty to Warn" laws. 






Lesson 6 Quiz

Instructions: Read the case study below then select an assessment tool (Columbia_Suicide_Severity_Rating_Scale, Suicide Assessment Example or SAFE-T Card - A five step suicide evaluation). Apply your selected suicide assessment screening tools to this case below. You will need to make up some additional information about this client to help you make your decision. Once you have completed this process then go into the quiz and answer the first 3 questions in the quiz. Then answer Questions 4 and 5, which involve other information you have read about this week.

  1. Tell me which tool you used. Share with me how you felt trying to apply the tool to the case study.
  2. What did you determine his risk to be? What does that mean you do next? Please outline for me the next steps you would take to help Mr. Green.
  3. What did you think of this activity? What were some of the challenges?

Case Study for Quiz above: Mr. Green is a 57 year old male with aggressive prostate cancer who is receiving care by the nursing team in the oncology department of a general hospital in Brisbane, QLD, Australia. Mr. Green was diagnosed with prostate cancer seven years ago but refused medical and surgical treatment at the time. He chose to seek alternative treatment and did not follow up with the urologist over that seven year period. Mr. Green has now presented with some new medical conditions. After several diagnostic tests over a period it was discovered that the cancer had metastasized to his bones, it had spread locally to his lymph nodes and the primary tumor was invading the bladder and partially obstructing the left kidney. Mr. Green had several medical hospital admissions over a two month period for various reasons. On the last admission Mr. Green was told that he may only have 4–6 weeks (previously it was 6–12 months) to live after a scan showed further extensive growth of the tumor. It was determined that any further surgical/medical intervention would not be appropriate in this case and that a palliative care regimen was the next step. Mr. Green's wife died 10 years ago and his only living adult child, Jonathan and his wife, live in Germany. At this point Mr. Green reported to the social worker on his medical care team that he had resigned himself to the fact that he was going to die. Mr. Green pulled then told the social worker that he planned to kill himself and that is was a secret that the social worker was not to tell anyone.

4. Describe your understanding of the limitations of confidentiality and the "Duty to Warn".

5. Evaluate the use of the app described below. This may be a resource that you would use as a professional in the field or provide to family members who have people in their lives at risk for self harm. Download and review the app. Discuss how you might incorporate the use of this app in your current &/or future practice. Does the app provide accurate and useful information?

SAMHSA Suicide Safe App is a training tool for healthcare providers to reduce client suicide risk by using the SAFE-T Approach. SAMHSA stands for the federal Substance Abuse and Mental Health Services Administration. It is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

Suicide Safe by SAMHSA by SAMHSA

Click this link to access the app in the App Store: https://itunes.apple.com/us/app/suicide-safe-by-samhsa/id968468139?mt=8

Lesson 6 Discussion (for online course only)

After viewing the four talks at the end of the lesson- think about the types of crisis one can experience, the bio-psycho-social model, Maslow's hierarchy of needs, and the definition of crisis as PERCEPTION. Select at least ONE of these topics and discuss it in your post.