HAL S.

WORTZEL, MD
SEAN M. BARNES, PhD
Law and Psychiatry KAILY A. CANNIZZARO, PsyD
EDGAR J. VILLARREAL, PhD
BRIDGET B. MATARAZZO, PsyD
Welfare Checks and Therapeutic Risk Management MICHAEL H. ALLEN, MD

In clinical practice, welfare checks have become documentation around a clinician’s choice to request (or
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a fairly common aspect of suicide prevention. At not request) a welfare check.

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the same time, the medical literature provides

almost no guidance to inform clinicians under
what circumstances welfare checks should be THERAPEUTIC RISK MANAGEMENT AND
requested, how best to go about placing those WELFARE CHECKS
requests, or how to document decision-making
related to this important subject. Literature We have previously described an approach to sui-
searches spanning both PubMed and Google cide risk management that is predicated on the
Scholar failed to yield any applicable results. principle of therapeutic risk management,1–5 and
Performed correctly, welfare checks have the now we extend this approach to encompass clinical
potential to be life-saving interventions for per- decision-making related to welfare checks. In 2009,
sons in suicidal crises. Performed incorrectly, Simon and Shuman6 presented the following
welfare checks may become an overly defensive description.
practice that damages therapeutic relation- Therapeutic risk management affirms the clini-
ships, violates patients’ rights, and consumes cian’s role in the treatment of the suicidal
important and limited community resources. patient. It requires a working knowledge of the
The need for thoughtful guidance to assist legal regulation of psychiatry to inform appro-
clinicians in navigating these difficult clinical priate clinical management of legal concerns
scenarios is long overdue. This column, the that frequently arise regarding suicidal patients
second in a 2-part series, offers an approach to in crisis …. Therapeutic risk management is an
welfare checks informed by the tenets of ther-
apeutic risk management. WORTZEL: Michael K. Cooper Professor of Neurocognitive
(Journal of Psychiatric Practice 2019;25;470– Disease; Director of Neuropsychiatry; Associate Professor in
Psychiatry, Neurology, and Physical Medicine & Rehabilita-
474)
tion; and Faculty for the Forensic Psychiatry Fellowship at
the University of Colorado School of Medicine, Aurora, CO.
KEY WORDS: suicide, welfare checks, wellness He is also Director of Neuropsychiatric Services for the Rocky
checks, risk management Mountain MIRECC at the Rocky Mountain Regional VA
Medical Center, Aurora, CO; BARNES, CANNIZZARO:
Clinical and Research Psychologists with the Rocky Mountain
MIRECC. Dr Barnes is an Assistant Professor in the Depart-
As discussed in the first column in this 2-part series, ment of Psychiatry at the University of Colorado School of
welfare checks (also referred to as wellness checks—not Medicine, Aurora, CO; VILLARREAL: Suicide Prevention
to be confused with financial aid from the government) Manager for the VA Eastern Colorado Health Care System,
Aurora, CO; MATARAZZO: Director of Clinical Services for
are not an entirely benign intervention. In fact, a
the Rocky Mountain MIRECC and Associate Professor in the
number of articles in the popular press describe tragic Department of Psychiatry at the University of Colorado
outcomes that had obviously not been the intent of School of Medicine, Aurora, CO; ALLEN: Medical Director for
those requesting the welfare check or of those deliver- Psychiatric Emergencies and Telehealth at UCHealth, Med-
ing it. While catastrophic outcomes involving death or ical Director of Rocky Mountain Crisis Partners and Professor
of Psychiatry and Emergency Medicine at the University of
serious injury are probably very rare events, more
Colorado School of Medicine, Aurora, CO
commonplace adverse consequences also warrant con-
Copyright © 2019 Wolters Kluwer Health, Inc. All rights
sideration; an unwanted and/or unwelcome visit by law reserved.
enforcement may be damaging to therapeutic treat-
Please send correspondence to: Hal S. Wortzel, MD, Rocky
ment relationships, potentially complicating the Mountain MIRECC, Rocky Mountain Regional Medical
patient’s ability to engage in gainful therapies, and may Center, 1700 North Wheeling Street, Building G3 Room
jeopardize opportunities to assess and manage suicide 185, Aurora, CO 80045 (e-mail: [email protected]).
risk on an ongoing basis. Given these realities, there is The authors declare no conflicts of interest.
clearly a need for thoughtful decision-making and DOI: 10.1097/PRA.0000000000000434

470 November 2019 Journal of Psychiatric Practice Vol. 25, No. 6

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

 LAW AND PSYCHIATRY

essential part of good clinical care. It supports principle of beneficence. At the same time, by virtue
the patient’s treatment and the therapeutic of relaying this suicidal crisis to a treatment pro-
alliance. The pervasive ethic is beneficence and, vider, the patient is expressing at some level a need
“First do no harm.” Therapeutic risk manage- and/or desire for assistance and support. Hence,
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ment avoids defensive practices of dubious sending help is also generally aligned with
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benefit that, paradoxically, can invite a malprac- autonomy, especially if this intervention had pre-
tice suit. Moreover, an unduly defensive mindset viously been discussed in the context of safety
can distract the clinician from providing good planning. The provider might communicate that he
patient care.6(p157) is having a team member call for a welfare check,
and then stay on the line to offer support, in a
As with therapeutic risk management of the sui- fashion that informs and prepares the patient for
cidal patient more generally, the intent is to have a the impending welfare visit and mitigates any risk
cogent approach to decision-making about welfare of harm. Under such circumstances, thoughtful
check requests in place, so that clinical choices are efforts to balance risks, benefits and ethical princi-
born of a rational balancing of risks, benefits, and ples support the rational use of a welfare check.
competing ethical principles and are not unduly Now consider a scenario in which a provider has
influenced by clinician anxiety. a chronic high-risk patient who fails to present for a
Generally speaking, the nature and magnitude of scheduled appointment. Outreach telephone calls
suicide risk faced by patients should be known to go unanswered, and several hours have passed
providers well in advance of the need for a welfare without a return phone call. Do these circum-
check. This creates the opportunity to put welfare stances justify a welfare check? An analogous
checks into the context of safety planning and process that considers risks, benefits, and guiding
informed consent. The patient at elevated risk for ethical principles yields a different result. Benefits,
suicide ought to be informed of his or her risk and or the potential to realize beneficence, seem ques-
the provider’s concerns about suicide risk, current, tionable at best under these circumstances. Stated
and future, which then drives the development of a differently, the potential benefit depends largely on
safety plan, including steps to engage others when a the likelihood that the patient is actually experi-
specified threshold is crossed. The plan may include encing an acute suicidal crisis, and that emergency
a number of options identified by the patient as responders deployed would arrive in the midst of
preferable, in his or her view, to law enforcement such a crisis. Even individuals at high chronic risk
involvement. A release of information and guidance for suicide spend most of the day, nearly every day,
on how to engage with identified supports can be not in the midst of an acute suicidal crisis. What is
part of the plan, ready to be invoked as needed. the likelihood that an essentially blind welfare
Means safety and other elements of safety planning check might present at just the right moment to
may be covered concurrently. Ideally, these steps avert an otherwise lethal suicidal crisis? Proba-
will reduce, and often obviate, the need for welfare bility almost dictates that far more commonplace
checks, or at least keep decision-making related to circumstances account for the missed appointment
such checks in the hands of trusted individuals. and unanswered outreach attempts (eg, the patient
Indeed, it is often difficult to treat high-risk is not at home, forgot about the appointment,
patients without such a partnership. marked the calendar incorrectly, was in the
Clinical scenarios usefully illustrate the intended shower, had some other urgent matters come up).
process. Take, for example, a situation in which a Alternatively, unlike the patient in the previous
provider receives a call from a patient that is example, this patient did not reach out for support
unequivocally describing an acute suicidal crisis. or assistance. Hence, even if a welfare responder
Given that circumstance, the potential that a wel- arrived and established contact, the patient might
fare check might represent a genuine life-saving respond in a way that conceals any distress or crisis
intervention seems considerable (we are fairly cer- or might offer some explanation to diffuse the
tain that the patient is acutely suicidal right now encounter. In short, the likelihood that this blind
and might not be able to maintain safety absent welfare check turns out to be life-saving seems
external support), consistent with the ethical exceedingly low. At the same time, the risk for

Journal of Psychiatric Practice Vol. 25, No. 6 November 2019 471

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 LAW AND PSYCHIATRY

harm, as well as deprioritization of autonomy and policy is clearly drafted in a manner that seeks to
nonmalficence, seems substantial, given that no achieve the sort of balance across risk, benefit, and
help was sought or requested and that the patient guiding ethical principles described above. It
might be very surprised and/or distressed by the assumes that a collaborative process that includes
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unexpected arrival of police at the home. The risk the service user in decision-making will achieve a
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for harm seems substantial, ranging from a dam- better result. The guide emphasizes an approach to
aged therapeutic relationship to a violent police the suicidal patient that utilizes the least invasive
encounter. intervention possible:
Needless to say, innumerable possible circum- Use the least invasive intervention and con-
stances may make up any given actual clinical sider involuntary emergency interventions as a
scenario, many of which are impossible to antici- last resort …. Center Staff shall:
pate, and certainly can’t be accounted for in a pub- i Seek to collaborate with individuals at
lication of the present sort. For example, if the Imminent Risk …; and
clinician were aware of acute psychosocial stressors ii Include the individual’s wishes, plans, needs,
or circumstances that historically had been asso- and capacities towards acting on his/her own
ciated with previous suicide attempts, this might behalf to reduce his/her risk of suicide, wherever
alter the equation. The point is that, while there is possible.8(pvi)
often no clear right or wrong answer to the bal-
ancing act described above, the act of considering The guide does allow for the initiation of life-saving
potential risks and benefits and seeking to optimize services and active rescue “up to and including
competing ethical principles, represents a process calling an emergency service provider,” when less
that is more likely to yield rational clinical decision- invasive methods have proven inadequate, and when
making in a fashion that is defensible no matter the suicide seems imminent:
outcome and that helps to achieve the goals of To the degree it is evident to Center Staff
therapeutic risk management. that a suicide attempt is in progress, … Center
Guidelines shall direct Center Staff to under-
take procedures to ensure that the individual
APPLICABLE GUIDANCE FROM THE NATIONAL
at risk receives emergency medical care as soon
SUICIDE PREVENTION LIFELINE
as possible.8(pvi)
As discussed in the first column in this series, the
medical literature offers very little guidance to men- In balancing various risks, benefits, and compet-
tal health clinicians faced with the choice of whether ing ethical principles, the guide seems to come to
or not to request a welfare check. That said, some the conclusion that invasive utilization of welfare
data are available from the National Suicide Pre- checks is only justified when other more collabo-
vention Lifeline survey of its centers. In 2018, with rative methods of active engagement have failed,
69% of centers responding representing 80% of net- and when risk remains imminent. The following
work volume, only 2.1% of calls involved a rescue. Of definition of imminent risk is offered:
these, 61% were initiated in collaboration with the Imminent Risk: A Caller is determined to be
caller.7 This means that in <1% of the cases was it at imminent risk of suicide (“Imminent Risk”) if
necessary to use the 9-1-1 system and many of these the Center Staff responding to the call believe,
were not suspected or threatened attempts, but based on information gathered during the
actual attempts in progress. Seen from this per- exchange from the person at risk or someone
spective, the unwitting or noncollaborative use of law calling on his/her behalf, that there is a close
enforcement would seem to be very rare. temporal connection between the person’s
The National Suicide Prevention Lifeline has also current risk status and actions that could lead
gone to great lengths to think through this problem to his/her suicide. The risk must be present in
with committees of national experts and persons the sense that it creates an obligation and
with lived experience. Although Lifeline’s Policy for immediate pressure on Center Staff to take
Helping Callers at Imminent Risk of Suicide8 is urgent actions to reduce the Caller’s risk; that
framed using somewhat different language, the is, if no actions are taken, the Center Staff

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 LAW AND PSYCHIATRY

believe that the Caller is likely to seriously consistent (across providers) approaches to such
harm or kill him/herself. Imminent Risk may patients is vital when teams endeavor to implement
be determined if an individual states (or is behavior plans intended to extinguish maladaptive
reported to have stated by a person believed to behaviors and replace those with thoughts and
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be a reliable informant) both a desire and actions that are more consistent with overall
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intent to die and has the capability of carrying treatment goals and therapeutic engagement.
through his/her intent (see National Suicide Medicolegally, documenting clinical rationale and
Prevention Lifeline Suicide Risk Assessment actions concretely demonstrates what was done and
Standards Packet for further clarification).8(pix) why. This can be especially important in relation to
things which were considered but not done, such as
The guide also offers a number of useful recom- a welfare check. By carefully documenting why a
mendations in terms of approaches mental health welfare check was not initiated, the clinician
professionals might employ before requesting a establishes deliberation concerning that possible
welfare check by emergency responders. Examples intervention, as well as the reasoning behind the
include: obtaining agreement from the patient to course of action that was ultimately chosen. In
take some action to reduce risk on his or her own; other words, documentation should demonstrate a
obtaining agreement to participate in an in-home thoughtful clinical decision and help ensure that it
evaluation by a mobile crisis or outreach team; is not misconstrued as a negligent omission.
obtaining agreement to participate in a 3-way call As modeled earlier in this column, documentation
with a treatment provider; securing transportation should include explicit reference to the potential
to a local hospital for evaluation and treatment; risks and benefits that were weighed against each
obtaining agreement to allow a significant other other. In relation to welfare checks, this will typi-
to intervene in a manner which better assures cally involve some discussion regarding why a wel-
safety. fare check would, or would not, be likely to result in
a life-saving rescue. Pertinent considerations might
include evidence of imminent risk for suicide, or the
DOCUMENTATION STRATEGIES
lack thereof, or if/how welfare checks feature in the
As with other aspects of suicide risk assessment safety plan. Risks also warrant consideration. For
and management, the realization of therapeutic example, an unwelcome welfare check might dam-
risk management requires thoughtful doc- age a tenuous treatment relationship and interfere
umentation, for both clinical and medicolegal rea- with future efforts to assess and mitigate suicide
sons. Clinically, a medical record that carefully risk. What if the patient has articulated a disdain
depicts assessment and clinical decision-making for law enforcement, or even a potential plan to
facilitates meaningful communication across pro- suicide by cop?
viders. In the context of suicidal risk management Providers working with patients at high chronic
more generally, and the use of welfare checks, in risk may explore thoughts and feelings about welfare
particular, such documentation will help providers checks with these patients, while simultaneously
across a system of care practice in a fashion that is offering important education. Documentation could
more uniform and mutually reinforcing of one include an informed consent–type of discussion with
another, with clear and consistent messaging in the patient concerning sentiments and wishes in
relation to how suicidal statements and behaviors relation to welfare checks. Some patients might
are managed. This can be particularly useful in clearly articulate that they are not interested in
cases in which suicidal statements are frequently having emergency responders sent to their homes
offered, seemingly as a means of communicating unless they have explicitly asked for it. Others might
distress or having needs met, although they seldom indicate being less averse to the potential for visits by
result in actual suicide attempts. Such cases often police. Such dialogues create opportunities to estab-
result in challenging and/or contentious decisions lish ground rules for talking about suicide and what
about whether a welfare check is really appropriate would precipitate actions such as a welfare check
or potentially countertherapeutic. Careful doc- and/or involuntary admission, as well as presenting
umentation that facilitates collaborative and the opportunity to discuss some important clinical

Journal of Psychiatric Practice Vol. 25, No. 6 November 2019 473

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 LAW AND PSYCHIATRY

realties. As previously alluded to, it is exceedingly risks associated with requesting a welfare check (or
unlikely that a blind welfare check will arrive during not), while simultaneously striving to optimally
the precise window of opportunity to avert a death by adhere to the guiding ethical principles of autonomy,
suicide. Hence, providers can truthfully point out nonmaleficence, and beneficence. Documentation
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that the ability to deploy life-saving interventions is should reflect that process, clearly articulating the
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intimately connected to a patient’s willingness to rationale leading to the course of action taken.
utilize safety plans and reach out for assistance when Finally, providers may proactively engage patients at
it is needed. Such discussions establish appropriate high chronic risk for suicide in dialogues about wel-
expectations in relation to agency and self-efficacy in fare checks in an informed consent-like process and
one’s own care and safety management and address as part of safety planning, simultaneously eliciting
false expectations that miraculous rescues might patient preferences while offering education about
spontaneously occur. suicidal communications and the importance of
agency and self-efficacy in suicide prevention.
CONCLUSIONS
Ongoing efforts to curb our nation’s suicide crisis
include the use of welfare checks. But the expect- REFERENCES
ations, and implications, of mental health pro- 1. Wortzel HS, Matarazzo B, Homaifar B. A model for
fessionals initiating welfare checks remain rather therapeutic risk management of the suicidal patient.
J Psychiatr Pract. 2013;19:323–326.
unclear, and there is almost no guidance in the 2. Homaifar B, Matarazzo B, Wortzel HS. Therapeutic risk
medical literature on this point. There is a readily management of the suicidal patient: augmenting clinical
apparent need for research to inform the use of wel- suicide risk assessment with structured instruments.
J Psychiatr Pract. 2013;19:406–409.
fare checks and to determine to what extent and 3. Wortzel HS, Homaifar B, Matarazzo B, et al. Therapeutic
under what circumstances they are helpful. In the risk management of the suicidal patient: stratifying risk
meantime, it seems reasonable to assume that, by in terms of severity and temporality. J Psychiatr Pract.
2014;20:63–67.
virtue of their training and fiduciary relationships 4. Matarazzo BB, Homaifar BY, Wortzel HS. Therapeutic
with their patients, clinicians requesting welfare risk management of the suicidal patient: safety planning.
checks will be held to some standard of care— J Psychiatr Pract. 2014;20:220–224.
5. Borges LM, Nazem S, Matarazzo B, et al. Therapeutic risk
especially when clinical decisions are associated management: chain analysis. J Psychiatr Pract. 2019;
with adverse outcomes. However this standard of 25:46–53.
care might evolve, an approach informed by the 6. Simon RI, Shuman DW. Therapeutic risk management
of clinical-legal dilemmas: should it be a core compe-
tenets of therapeutic risk management seems pru- tency? J Am Acad Psychiatry Law. 2009;37:155–161.
dent. It is imperative that providers recognize wel- 7. National Suicide Prevention Lifeline. Vibrant Emotional
fare checks for all that they are and not operate Health: National Suicide Prevention Lifeline Crisis
Center Survey (FY2018). Internal report, unpublished.
under false notions that they are a risk-free and cost- 8. National Suicide Prevention Lifeline. Policy for Helping
free intervention. Instead, clinicians considering a Callers at Imminent Risk of Suicide, New York, NY:
welfare check must attend to the circumstances of National Suicide Prevention Lifeline; December 2010.
Available at: https://suicidepreventionlifeline.org/wp-
each specific patient and his or her particular needs content/uploads/2016/08/Lifeline-Policy-for-Helping-Callers-
and endeavor to weigh the potential benefits and at-Imminent-Risk-of-Suicide.pdf. Accessed August 18, 2019.

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