Suicide and the Law

SUMMARY

The purpose of this chapter is to delineate how mental health professionals can prevent their clients from acting in a suicidal manner while protecting themselves against potential liability when a client attempts or completes suicide. In our increasingly litigious society mental health professionals can apply their understanding about the elements of legal liability in cases involving client suicidal behaviors to structure their services in a manner to meet their responsibility in treating potentially suicidal clients.     

‘What meaning does somebody's death have,what meaning does somebody's life have?’ Psychotherapists’ stories of their work with suicidal clients

Working with suicidal clients is perceived to be demanding and anxiety provoking for psychotherapists. This investigation explores what it is like for psychotherapists who work with suicidal clients, particularly as within the prevailing culture there is an increasing focus on strategies aimed at suicide prevention. Five themes were identified through narrative analysis, with support systems such as supervision and peer support being seen as vital in surviving working with suicidal clients. However, there is also ambivalence about involving other professionals, such as mental health services, as there is a sense that to do so may be anti-therapeutic and unhelpful to the client. Overall, what emerges from this study is that it is important to challenge the prevailing culture in which a medical discourse is dominant, in order to find a different way of talking about suicide and despair.     

Suicide prevention in the genetic counseling context

Utilizing a case report, this paper explores psychosocial aspects of suicidal intent in a woman seeking prenatal diagnosis. Using knowledge and practice of appropriate assessment, referral, and intervention procedures, the therapy team of genetic counselor and psychotherapist facilitated successful identification and management of this potentially suicidal client. The main counseling goals for the genetic counselor are to assess the situation adequately, decrease the immediate danger, and, with supervision and/or consultation, stabilize the seriously suicidal person until that individual can be triaged to mental health or medical professionals for treatment. The prevalence of suicide issues in genetic counseling contexts is unknown and reports mentioning suicidal ideation unusual in the genetic counseling literature. Is this reported case a rarity among genetic counseling referrals? Systematically collected information on the prevalence and resolution of suicidal issues in genetic counseling contexts would be helpful for those setting curricula for genetic counseling training programs, standards for professional certification exams, and policy and procedures manuals for clinical units.     

Follow‐up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers’ Perceptions of Care

Continuity of care for suicidal individuals engaged with a variety of health and mental health care systems has become a national priority, and crisis hotlines are increasingly playing a part in the risk management and continuum of care for these individuals. The current study evaluated a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow‐up care to suicidal callers. Data were obtained from 550 callers followed by 41 crisis counselors from 6 centers. Two main data sources provided the information for the current study: a self‐report counselor questionnaire on the follow‐up activities completed on each clinical follow‐up call and a telephone interview with follow‐up clients, providing data on their perceptions of the follow‐up intervention's effectiveness. The majority of interviewed follow‐up clients reported that the intervention stopped them from killing themselves (79.6%) and kept them safe (90.6%). Counselor activities, such as discussing distractors, social contacts to call for help, and reasons for dying, and individual factors, such as baseline suicide risk, were associated with callers’ perceptions of the impact of the intervention on their suicide risk. Our findings provide evidence that follow‐up calls to suicidal individuals can reduce the perceived risk of future suicidal behavior.     

Rational Suicide: An Empirical Investigation of Counselor Attitudes

This study investigated attitudes of mental health counselors toward rational suicide. Over 80% of respondents were moderately supportive of the idea that people can make well‐reasoned decisions that death is their best option, and further, they identified a consistent set of criteria to evaluate such decisions. Additionally, analyses revealed that as the scenario moved from client, to friend, to self, rational suicide seemed to gain in acceptability for these professionals. Implications for training and practice in light of the apparent responsibilities with suicidal clients defined in the 1995 American Counseling Association's Code of Ethics and Standards of Practice are discussed.     

A solution-focused approach to working with clients who are suicidal

Self-harm and suicide are amongst the most challenging and frightening problems that therapists and counsellors can encounter in the course of their work. The risk of clients harming themselves in the course of treatment can debilitate the therapists from acting creatively and collaboratively, and make their actions defensive, focused solely on risk assessment rather than therapeutic change.Yet it is precisely a creative and collaborative response, such as that engendered by solution-focused therapy and other models, that is the most likely to facilitate change and re-empower clients to take back charge of their lives. This article describes a solution-focused approach to working with suicidal clients that can be used in conjunction with traditional approaches and which focus on establishing safety as well as assessing risk.Working from this model the clinician shifts to identifying client strengths and coping skills, to collaborating with the client to establish meaningful goals and to helping the client envision a positive future. Arguably, such an approach can increase collaboration between therapist and client and lead to a more client-centred safety plan.     

“One Size Fits All”: An Existential-Constructivist Perspective on the Crisis Intervention Approach with Suicidal Individuals

The empirical data on the relationship between suicide and suicide attempts are interpreted as suggesting that the contemporary assessment and intervention approaches to suicidal individuals are, by and large, ineffective. In support of our argument, we focus on the crisis intervention model as one example and suggest that the crisis intervention approach to responding to suicidal individuals is at best, ineffective and, at worst, can be viewed as exacerbating suicidal risk through its distancing, marginalizing, and stigmatizing effects. Additionally, we hypothesize that the mechanics of the crisis intervention model contribute to the societal message that a meaning and contextual-based discussion of suicidality is taboo and that this message tends to continue into more long-term psychotherapeutic approaches. Along these lines, we present an alternative to the crisis intervention model grounded in an existential-constructivist theory of suicidal behavior and the principles of therapeutic and feminist assessment philosophies as an heuristic intended to stimulate the development of new and innovative approaches to working with suicidal individuals.     

Intervention Styles With Suicidal Callers at Two Suicide Prevention Centers

Callers to suicide prevention centers are mainly helped by volunteers trained to face these crisis situations. This study evaluated this process of intervention in order to better understand the nature of the interventions and their determinants. A total of 617 calls with suicidal clients were classified with a 20-category rating instrument, the Helper's Response List. Cluster analysis determined that the 617 intervention profiles could match one of two styles: nondirective (“Rogerian”-391 calls) or directive (226 calls). Further analyses indicated that the particular style of intervention was related more to the characteristics of the callers themselves than to characteristics of volunteers.     

Suicide Intervention Skills and Related Factors in Community and Health Professionals

Health and community professionals have considerable exposure to suicidal people and need to be well skilled to deal with them. We assessed suicide intervention skills with a Dutch version of the SIRI in 980 health and community professionals and psychology students. Suicide intervention skills clearly differed among professional groups and were strongly related to experience, especially suicide‐specific experience. Some community professionals scored below acceptable levels on their ability to respond appropriately to suicidal people they encounter, and tended to overestimate their skills level. Training is therefore indicated for these groups, and may be useful to more highly experienced groups too.     

Racial differences in self-disclosure of suicidal ideation and reasons for living: implications for training

Racial differences in suicidal self-disclosure and reasons for living were investigated in 2 separate studies. In Study 1, a random sample of archival client and therapist intake data from a university counseling center for 1 year was examined, and results indicate that ethnic minority clients do not self-disclose suicidal ideation as readily as their nonethnic minority peers. In addition, a significantly higher number of ethnic minority clients were deemed "hidden ideators" because their suicidal ideation only became evident when a counselor performed a suicide risk assessment. Only 1 of the 36 ethnic minority clients with suicidal ideation in the sample voluntarily self-disclosed this ideation at intake without an assessment by the therapist. Study 2 used the Reasons for Living Inventory (RFL) and compared African American and European American college students from an introductory psychology course. The RFL is a useful instrument to compare potential race differences in reasons people report for choosing not to kill themselves, because it does not require respondents to self-disclose (or to have) current suicidal ideation. The results from Study 2 indicate European Americans report fewer reasons for choosing not to kill themselves than their African American peers and that African Americans scored significantly higher than European Americans on the moral objections and survival and coping beliefs subscales of the RFL. Implications for training counselors in suicide risk assessment, prevention, and treatment with ethnic minorities are discussed.     

Addressing Concealed Suicidality: A Flexible and Contextual Approach to Suicide Risk Assessment in Adults

Concealed suicidality can be a major impediment for clinicians conducting a suicide risk assessment. Client minimization and denial of suicidal thoughts can lead clinicians to undertreat and under-monitor clients experiencing a suicidal crisis. Five recommendations are given to address potential weak areas of suicide assessment with adults including routinized processes and a reliance on assessment instruments that may underestimate risk when individuals have no prior attempts or significant mental illness. Specifically, the authors highlight the importance of continued training and education in suicide assessment, how considering the context of the assessment can heighten one’s sensitivity to concealment of suicidal ideation and how different assessment instruments and interview techniques, when chosen with care, can increase the candor of client expression. The authors also recommend attending to clinician anxiety both as a way of maintaining rapport as well as a method of identifying clues that the assessment is not producing accurate information. Finally, application of recommendations is demonstrated through case vignettes.

     

Graduate training and the treatment of suicidal clients: the students' perspective

Existing literature suggests that graduate programs may not provide adequate training in working with suicidal clients. Therefore, we surveyed 238 predoctoral psychology interns and assessed the prevalence of clients engaging in suicidal behaviors and the amount of formal training in managing suicidal clients received. Results showed approximately 5% of participants indicated a client suicide and 99% indicated they had treated at least one suicidal client during their graduate training. In contrast, results demonstrated only 50% of the participants reported attending programs where formal training was offered. These findings suggest a continued need for increased formal training in managing suicidal clients in graduate psychology programs.     

The Practice of Suicide Assessment and Management by Marriage and Family Therapists

Abstract

Over 90% of mental health providers encounter suicidal clients. However, the majority of marriage and family therapists (MFTs) are not exposed to suicide-specific trainings within their clinical coursework. Due to the lack of consistent training protocols for suicide assessment and management among MFTs, this qualitative study identified common MFT responses to suicidal clients, including assessment of risk severity and intervention modalities. Responses were then compared to best practices for suicidal clients. Participants inconsistently adhered to best practices identified in the larger field of mental health, revealing the need for increased MFT training on suicide to ensure appropriate and effective care.     

Death anxiety and counseling skill in the suicide interventionist

In light of recent evidence that suicide intervention workers may experience greater fear of death than the general population, the present study examined the death anxiety of interventionists and its relation to skill in responding to suicidal clients. A sample of 109 suicide prevention workers from three independent crisis centers were administered the Death Anxiety Scale (Templer, 1970) and the Suicide Intervention Response Inventory (Neimeyer & MacInnes, 1981). Compared to 109 matched controls, the interventionists were found to have significantly lower death anxiety, thereby reversing the earlier finding. Moreover, no linear or curvilinear relationship between death anxiety and suicide counseling skill could be identified. Together, these results give some justification to the traditional neglect of death concern as a factor in screening or training crisis intervention personnel.     

No-harm contracts: a review of what we know

Few events in the practice of a mental health clinician can be as devastating as the suicide of a client. Although suicide is a rare occurrence, clinicians face assessment of clients' risk for harming themselves on a regular basis. One well-accepted and widely practiced intervention for suicidal ideation is the use of no-harm contracts (NHC), although opinions about NHCs range from enthusiasm to apathy. The existing research does not support the use of such contracts as a method for preventing suicide, nor for protecting clinicians from malpractice litigation in the event of a client suicide.     

Evaluation of a Suicide Prevention Center by Sampling the Population at Risk*

ABSTRACT: At present there are no clear guidelines for assessing the effectiveness of suicide prevention and crisis centers. This report focuses on one readily available source of data, specifically that segment of the population at risk made up of persons admitted to the inpatient service of a mental health center due to depressive and/or suicidal states, including suicide attempts. To determine the role of the suicide prevention center in providing services to this group, 575 persons meeting these criteria were interviewed. The findings included the following: (a) 11 percent had utilized suicide prevention center services, with 59 percent of these experiencing substantial benefit; (b) 20 percent stated they were unaware of the center; (c) 8 percent expressed the view that calling the center would be inappropriate because a suicide attempt was not imminent; and (d) 26 percent indicated an inclination to call the center in the event of subsequent difficulties. Experience suggests that response to a crisis (intervention) as well as response to low lethality callers with “everyday problems” (prevention) constitute valid functions of a suicide prevention and crisis center. Preoccupation with short-term goals, such as reducing the apparent suicide rate, should not dominate the conceptualizing of program evaluation methods.     

A test of the effectiveness of a list of suicide warning signs for the public

In this study we examined the effect that reading a list of warning signs for suicide has on beliefs about suicide, including the belief that one can recognize a suicidal crisis. All participants read two sets of warning signs (with only the experimental group reading the suicide warning signs) and then answered questions concerning beliefs related to three health problems. Results indicate that participants who read the suicide warning signs reported greater abilities to recognize if someone is suicidal but did not report stronger beliefs that suicidal individuals are partly to blame, nor did they report lower likelihoods of befriending suicidal individuals. Results suggest that reading the list of warning signs may be effective in increasing the public's ability to recognize suicidal crises without creating or magnifying stigmatizing beliefs about suicidal individuals.     

Preventing suicide through improved training in suicide risk assessment and care: an American Association of Suicidology Task Force report addressing serious gaps in U.S. mental health training

There are twice as many suicides as homicides in the United States, and the suicide rate is rising. Suicides increased 12% between 1999 and 2009. Mental health professionals often treat suicidal patients, and suicide occurs even among patients who are seeking treatment or are currently in treatment. Despite these facts, training of most mental health professionals in the assessment and management of suicidal patients is surprisingly limited. The extant literature regarding the frequency with which mental health professionals encounter suicidal patients is reviewed, as is the prevalence of training in suicide risk assessment and management. Most importantly, six recommendations are made to address the longstanding insufficient training within the mental health professions regarding the assessment and management of suicidal patients.     

Rational suicide?

Abstract

Two competing paradigms of suicide imply different views of whether suicide can be rational. The first, the “received orthodoxy” of mental health professionals for more than a century, views all suicides as irrational and holds that suicidal persons should always be prevented from ending their own lives. The second grants that most suicides are irrational, but claims suicide may sometimes be a rational option. Lokhandwala and Westefeld's argument manifests the conflict between these two paradigms: After initially granting that suicide may be a rational option for some people, they in effect urge mental health professionals to presume in practice that any suicidal patient is irrational. Patients for whom suicide might indeed be rational will be ill-served by mental health professionals who follow Lokhandwala and Westefeld's advice.