Clinical situations involving high-risk factors (e.g., suicidality) can be stressful and demanding for therapists (Cramer et al., 2013; The Suicide and Self-Destructive Behaviors Study Group, 2018). Challenging client behaviors, including those related to high risk, have also been linked to burnout (Berger, 2011; Ross et al., 1989; Rupert & Morgan, 2005). Arguably, these factors can impact therapists’ competence (Simionato & Simpson, 2017).

Developmentally, early career psychologists have a higher risk of burnout than late-career psychologists (Craig & Sprang, 2010; Semionato & Simpson, 2017). Early career psychologists (ECPs) are transitioning from a student role to a professional role and face unique career adjustments and demands. Some of these demands include “starting a practice or career and starting a family” (Barnett, 2015), obtaining licensure, educational debt, and developing a professional identity (Green & Hawley, 2009). Newly licensed ECPs can also face the unique challenges of dealing with risk-related issues on their own for the first time (e.g., no direct supervisor guiding them) and stressors related to being the sole decision-maker (including changes related to liability). At the same time, many ECPs might be starting their licensed practice without the formal training needed for competency in the assessment and management of high risk-related issues. Furthermore, according to Groth & Boccio (2018), “practitioners’ formal graduate training in suicide risk assessment and management has been shown to be limited and, in many cases, inadequate” (p. 1241). 

When ECPs start a new phase in their career or take on a new role in their existing position, this can create a stressful and demanding process of learning new procedures, navigating added responsibilities, and feeling emotionally and physically stressed. In addition, many ECPs might be new supervisors, and therefore have to manage not only their clinical caseloads but those from their supervisees. 

All of these changes can be wonderful, growth-provoking, and engaging experiences. However, these experiences can also make ECPs feel vulnerable, especially when clinical situations require competence. Therefore, how can ECPs maintain their best selves in clinical situations involving risk? How do they connect with their secure base from which they can be curious, present, and helpful to clients?

Here are seven aspects to consider that might help us be our “best selves” when dealing with high-risk clinical situations.

Self-care

• Engage in self-care on an ongoing basis (Cramer et al., 2013). Self-care starts with maintaining “a general good baseline,” which includes adequate amounts of sleep and food intake (Barnett, 2015). Self-care strategies and activities will vary based on what works for each individual and might include exercising, meditation, seeking support from others, spending time outdoors, etc. Find what works for you.  
• Engage in self-care after dealing with a situation involving high risk to help restore you to your baseline. Examples of activities could include socializing, resting, completing a relaxation exercise, watching a video, using cognitive and behavioral coping strategies (Sim et al., 2016). Use anything that helps your body and mind reset.

Knowledge

• Learn specific content regarding risk-related issues, such as management of non-suicidal self-injury, suicidality, safety planning, homicidal risk, and substance use, among others.  Knowledge regarding specific questions for assessment, including risk and protective factors, is central for clinical work. Additionally, knowing about general theories (such as the Interpersonal Theory of Suicide) might provide a framework to understand the client’s experience. Opportunities to gain such knowledge might include professional development activities (e.g., taking CE credits and/or attending conferences such as the ones from the American Association of Suicidology), consultation with others in your workplace or community, and reading books and academic papers on the subjects. 
• Know the laws, protocols, and procedures regarding the management of high-risk situations. These can differ based on location and work environment. So, it is important to learn about protocols related to the specific place of work and the larger community (e.g., your state). 
• Document your work (Cramer et al., 2013).  

Consultation

• Engage in consultation regarding the case. This consultation can take the form of consulting with a colleague, discussing the case in a treatment team and/or crisis team, etc. All these activities have the value of bringing new information and/or perspectives to help us navigate challenging cases. Plan ahead regarding whom you could consult if needed (Cramer et al., 2013). Peer support can be highly valuable when navigating challenging clinical situations. 

Teamwork

• Determine if there is a network of people with whom you can coordinate care or can alert if concerns arise. This network might include a psychiatrist working with the student, parents, friends, or significant others. 
• If such a network is not in place, try to create one if possible. This might entail getting authorizations for release of information to parents and contacting them (unless the client is at imminent risk of hurting themselves or others, consent becomes unnecessary), connecting the client with a psychiatrist, and etc. Receiving assistance in a case involving high risk is not only good practice but might also help share the weight in cases that are too demanding to carry on one’s own (Cramer et al., 2013).

Awareness of Own Reactions

• Be mindful of the different thoughts and emotional reactions that you have before, during, and after a particular high-risk case; noticing how they might be affecting you and your work (Cramer et al., 2013; Joiner, 2005; Sim et al., 2016).
• Be aware of and work on your countertransference. There are many definitions of countertransference, though I’m considering it as the “…therapist’s internal or external reactions that are shaped by the therapist’s past or present emotional conflicts or vulnerabilities,” Gelso & Hayes, 2007, p.25). If you have experiences that might get in the way of your current work, it is central to understand and address them to be able to bring your best self forward. 
• Engage in ongoing self-reflection regarding risk-related situations. Consider your comfort when dealing with chronic and/or acute suicidality and/or homicidal thoughts, along with other risk factors. This knowledge could help you determine the type of work that might better suit you (where you can be your best self when dealing with risk). For example, this can be a factor in helping you choose between counseling centers – where staff members do not provide after-hours on-call services, where staff members provide such service, or a solo private practice versus a group practice where you might potentially have more support. 

Setting Boundaries

• Be mindful of and engage in setting boundaries (Sim et al., 2016). For instance, when working with a high-risk client, plan ahead of time and communicate when it is appropriate to contact you directly versus going to the emergency room. Boundaries can also be determined based on your own needs. For example, taking a pause when needed.  

Compassion

• High-risk situations can be distressing and having a compassionate attitude toward ourselves and toward those whom we work with can be highly beneficial. This compassion does not mean that as psychologists, we sanction every behavior. A compassionate attitude can be a way to remind ourselves that those who are in front of us are suffering, are here for a reason, and we are doing our best to help them in this process. This attitude can be especially challenging when dealing with clinical situations such as meeting with someone with homicidal ideation and high levels of anger. However, tapping into compassion might help lighten our emotional load, open the space for curiosity, and help us focus on what the client (and any others involved in the case) directly needs at this moment.

The different topics previously addressed are by no means an exhaustive list of aspects to address when working with challenging cases involving risk. Nonetheless, these suggestions can provide a roadmap of areas that early career psychologists might consider when working with such cases. These suggestions may also serve as guidelines that can bring out our best selves into the therapy room. Future research might illuminate specific recommendations for ECPs when dealing with risk in clinical settings, and how these guidelines might be similar and/or different to what is needed when dealing with risk during other periods in a psychologist’s career.

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Beatriz Palma, Ph.D.

Bea is a bilingual (English/Spanish) Licensed Staff Psychologist and Groups Coordinator at Counseling and Psychological Services (CAPS) at the University of Virginia (UVa) – Charlottesville. She earned a Ph.D. in Counseling Psychology from the University of Maryland-College Park, were her main areas of research were the therapeutic relationship, the person of the therapist, and psychotherapy process and outcome. Before coming to the US, she trained and worked as a Clinical Psychologist in Chile, her home country.