530.003 How to Deal With Clients Who Threaten to Harm Themselves or Others

1.0 Purpose

To guide contractors and subcontractors (Providers) in responding to a client’s violent or threatening behavior or when a client expresses suicidal ideation while providing HIV/STD prevention, clinical treatment, and social services under a contract with the Texas Department of State Health Services (DSHS), HIV/STD Section (Section).
 

2.0 Authority

Texas Health and Safety Code §611.002, Confidentiality of Information and Prohibition Against Disclosure; §611.004, Authorized Disclosure of Confidential Information Other than in Judicial or Administrative Proceeding; §81.046, Confidentiality; §81.103, Confidentiality, Criminal Penalty; HIV/STD Policy No. 530.002, Section Expectations and Provider Rights Regarding the Delivery of Client Services.
 

3.0 Definition as Used in this Policy

Professional – A person licensed or certified by the state or who is an employee of a facility licensed, certified, or operated by the state.

Provider -– A person, agency, or facility approved by the DSHS which has entered a contract with DSHS, or with a DSHS contractor, to deliver state or federal HIV/STD programs to clients.
 

4.0 Provider Rights When Dealing with a Client

Providers should develop written procedures to deal with clients who are violent or exhibit threatening behavior. DSHS expects Providers to use good judgment and attempt to resolve these situations fairly without denying services whenever possible, as long as the work environment can remain free from violence or threats. (See HIV/STD Policy No. 530.002, Section Expectations and Provider Rights Regarding the Delivery of Client Service.)
 

5.0 Responsibilities

5.1 Responding to clients who display violent or threatening behavior

When responding to clients who display violent or threatening behavior, staff should take the following actions as appropriate to the situation.

1. Call the proper authorities when a client threatens staff or other clients with a weapon or creates a situation where there is an immediate threat of injury or bodily harm.
2. Remain calm and speak at a low volume.
3. Summon a qualified mental health professional for help, if possible, or make a referral.
4. If possible, reschedule the client’s appointment for later that day or soon after.
5. Notify the leadership of patterns of violent or disruptive behavior that impacts the safety of staff and document a plan of action.
6. Pursue legal action as deemed appropriate by management if internal actions have been unsuccessful.
7. Follow up on any referrals or other actions taken to manage the client.
8. Document any action(s) taken in the client’s case file.
    

5.2 Responding to clients who make homicidal threats or exhibit homicidal behavior

Providers should take seriously any client who makes homicidal threats or exhibits homicidal behavior. Staff should attempt to take the following actions, as appropriate to the situation:

1. Remain calm and leave the area, if possible.
2. Alert another staff member, preferably a supervisor, to the situation (this person should call the police immediately).
3. If you are unable to safely remove yourself from the client or situation, try to calm the threatening individual (do not argue or talk back).
4. If safe to do so, summon a qualified mental health professional for assistance.
5. Notify the leadership of the contracting agency regarding serious client behavior problems for additional appropriate action.
6. Follow up on any referrals or other actions taken to manage the client.
7. Document any action(s) taken in the client’s file.
    

5.3 Responding to clients who exhibit suicidal ideation

5.3.1 Suicidal Ideation

Providers should take seriously any client who exhibits suicidal ideation. Qualified staff should appropriately screen clients to determine the severity of the threat before taking action. Unqualified staff should not attempt to diagnose the mental health status of clients beyond the identification of a potential suicidal situation. Staff may use the following questions to obtain more information from the client:

1. Ask the client if he or she has ever attempted suicide before.
2. Ask the client if they have a history of suicide in their family or if someone close to them has ever died by suicide.
3. Try to find out if the client has a plan to harm themselves.
4. Try to determine if the client has the means or intent to execute this plan.

5.3.2 Immediate Suicidal Threat

Any staff member confronted with an immediate suicidal threat should take the following actions as appropriate to the situation:

1. Encourage the client to stay on site until a mental health professional can determine the extent of the client’s need for further mental health assistance.
2. Assess the client’s willingness to talk with a mental health professional. If the client is willing, connect them to an available mental health professional as soon as possible.
3. If the client is already connected with a mental health professional, assist the client in contacting them.
4. Contact a family member or friend of the client, if the client is willing, and discuss a protection or safety plan.
5. Complete a “No Harm Agreement” (see attached example) covering the period from the current occurrence until the client’s next contact with a case manager or mental health provider (the client should keep a copy, and Providers should place a copy in the client’s record).
6. If none of the above are possible, the staff member should contact the appropriate mental health center and make a referral (the most likely contact is the local Mental Health Authority provider).
7. Give the client written instructions about how to contact their local crisis hotline and the local hospital emergency room.
8. If unsuccessful with the above, call 911 and request a mental health officer.
9. Notify the leadership of the contracting agency regarding concerning client behavior patterns that may warrant additional action.
10. Follow up on any referrals or other actions taken to support the client.
11. Document any action taken on behalf of the client in the client record.
     

5.4 Obligation to report

Communications between a client and a professional and records of the identity, diagnosis, evaluation, or treatment of a client created or maintained by a professional, are confidential (Health and Safety Code §611.002). However, a professional may disclose confidential information to medical or law enforcement personnel if the professional determines imminent physical injury is probable by the client to themselves or others, or there is a probability of immediate mental or emotional injury to the client (Health and Safety Code §611.004).
 

5.5 Where to go for help

When desired, the Provider may contact the HIV/STD Section to discuss specific situations or obtain technical assistance. Decisions regarding whether to continue, modify, suspend, or terminate client services remain with the Provider. (See “HIV/STD Policy No. 530.002, Section Expectations and Provider Rights Regarding the Delivery of Client Service” for more information.)

For an online directory of suicide hotlines, go to suicide.org/hotlines/texas-suicide-hotlines.html or call the National Suicide Prevention Lifeline at 988, or go to Lifeline (988lifeline.org).
 

6.0 Revision History