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Assessing a Client's Potential for Harm in Counseling

Instructor: Karin Gonzalez

Karin has taught middle and high school Health and has a master's degree in social work.

Often a person does not tell family and friends that they are suicidal or homicidal. It's up to a counselor to do a proper assessment for a client's potential for harm. Learn harm assessment questions, levels of risk, risk factors and behavioral warning signs in this lesson.

What Is Considered Harm?

Tami is a 30-year-old new mother and Army wife who is experiencing severe postpartum depression after having her first daughter, Avery. A counselor visits Tami at her home for weekly therapy sessions. In the initial interview with the counselor, Tami admits that she is incredibly lonely. The counselor decides to assess for potential for harm.

Assessing potential for harm in counseling means that a therapist will evaluate the possibility that someone will purposely harm themselves or others. It is essentially assessing risk for suicide, purposely and voluntarily ending one's own life, and homicide, or killing another or others. Unfortunately, mental illness and suicide are too prevalent in our society. In the United States, someone commits suicide every 16 seconds. Suicide is 50% more likely to occur than homicide, but that does not mean that homicidal risk should not also be assessed in counseling clients/patients with depression or mental illness.

If a client is severely depressed, assessing for potential for harm is a counselor's responsibility. Confidentiality, or keeping information discussed private, is a right of a client in counseling. But if a client reports that they want to harm themselves, harm someone else, or if a child, disabled or elderly person is currently being abused, a counselor must sometimes break confidentiality to protect the client or others from harm.

Harm Assessment Questions

The counselor asks Tami questions to assess if she has the potential to harm herself or others. Here are two ways Tami's counselor can ask if Tami has ever thought about suicide or homicide:

  1. Do you ever feel so depressed that you think it'd be easier if you just died?
  2. Are you thinking about hurting yourself or someone else?

Tami admits that she does sometimes think about killing herself. Now the counselor must assess if Tami has more than suicidal ideation, or thoughts of suicide; she must find out if Tami has a plan and means to commit suicide. In order to do this, she must get more specific with her questions to determine Tami's potential for hurting herself.

Some of these questions are:

  1. Have you ever come up with a plan or way to commit suicide? (If Tami answers yes, the counselor must get details as to how, when and where she would commit suicide.)
  2. Have you ever tried to kill yourself before?
  3. Do you have family members that have attempted or completed suicide?
  4. Are you on any medications or using any drugs/alcohol?
  5. Are there weapons in the house, such as a gun?
  6. Have you received counseling for suicidal ideation before?
  7. Do you have close friends or family members that help you when you are feeling down? (assessing support system)
  8. What are the (positive) things in your life that keep you from taking your own life?

Levels of Risk for Harm

From Tami's answers, the counselor can determine Tami's level of risk for harming herself. The different levels include:

  1. No thoughts of harming self or others
  2. Fleeting thoughts of harm, but has never thought of a plan of action
  3. Thoughts of harm and history of suicidal/homicidal behavior
  4. Thoughts of harm, has thought of a plan of action, but still not sure if s/he should carry out that plan
  5. Thoughts of harm and a detailed plan of when, how and where it will happen (e.g., 'I will kill myself tonight by taking a whole bottle of pain medication in my bedroom.')

Risk Factors for Harm

Next, the counselor may look at Tami's answers of her intake assessment and the questions above and identify risk factors, or things that increase the likelihood, for suicide or homicide.

Risk factors for harmful behavior are:

  • Access to weapons
  • History of (or family history of) suicide attempts
  • History of psychiatric illness (especially depression and bipolar disorder)
  • Feelings of hopelessness
  • Difficult life stressors such as loss of job, loss of relationship or death in the family
  • Lack of support system
  • History of child abuse/neglect/sexual abuse
  • History of impulsive or aggressive behavior
  • Lack of positive things in life (things to live for)

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