The psychotherapist's duty to act reasonably to prevent suicide: A proposal to allow rational suicide

It is proposed that society should re-examine its assumptions about suicide. Rational suicide is viewed as an extension of the right to die. After a review of the legal liability of the psychotherapist and psychiatric facility for both inpatient and outpatient suicide, the author presents an analysis of philosophical, ethical, and psychoanalytic arguments for allowing rational suicide. It is argued that emotional pain should be given more legitimacy as a reason for suicide. The decision to live or to die is argued to best rest with the individual.     

Collaborating to prevent suicide: a clinical-research perspective

It is argued that suicidality is essentially a relational phenomenon; the presence or absence of certain key relationships paradoxically can be both suicide causing and suicide preventive. The relational aspects of suicide are especially poignant in clinical work with suicidal patients. However, when suicidality is involved, there are a number of issues that can interfere with effective clinical practice. Fortunately, a new paradigm has begun to emerge in contemporary clinical suicidology, which objectifies suicidality and emphasizes the phenomenology of suicidal states. Moreover, from an increasingly empirical perspective, this approach is creating new and better ways to effectively assess and treat suicidal conditions.     

The two faces of conscientiousness: duty and achievement striving in escalation of commitment dilemmas.

The author proposes that 2 facets of conscientiousness, duty and achievement striving, affect decision makers in escalation of commitment dilemmas in opposing ways, thus masking the predictive ability of a broad measure of conscientiousness. It is proposed that duty is associated with an other-centered orientation and that achievement striving is associated with a self-centered orientation. Analyses of decisions from 360 respondents showed that duty was associated with a deescalation of commitment, achievement striving was associated with an escalation of commitment, and the broad measure of conscientiousness was unassociated with commitment. The author advocates the utility of understanding potential self-centered versus other-centered aspects of the criterion of interest when conducting personality-based research.     

A Kantian moral duty for the soon-to-be demented to commit suicide

It has been argued that, on Kantian grounds, pedophiles, rapists and murderers are morally obligated to take their own lives prior to committing a violent action that will end their moral agency. That is, to avoid destroying the agent's moral life by performing a morally suicidal action, the agent, while he still is a moral agent, should end his body's life. Although the cases of dementia and the morally reprehensible are vastly different, this Kantian interpretation might be useful in the debate on the permissibility of suicide for those facing dementia's effects. If moral agents have a duty to act as moral agents, then those who will lose their moral identity as moral agents have an obligation to themselves to end their physical lives prior to losing their dignity as persons.     

Ethical dilemmas in context: Some preliminary questions

I have tried to build on O'Neill's thought-provoking paper by examining two influences that shape and define ethical dilemmas in the community: our personal agendas and the broader context. The first influence is the way in which our personal and professional values shape our agendas for community work. The way these agendas frame the choices for action are a force to be recognized separate from the question of who constitutes our community constituency. Our values may push us into proactive roles and we must face the way our actions make personal/political statements. The broader context of the community situation and the ways in which resource limitations frame the ethical question also need to be actively recognized. Otherwise there is a danger of making the psychologist the victim by posing the ethical dilemma as a question of how they alone should find a solution. The nature of our personal agenda must be clear before we ask “responsible to whom?” The broader context must be considered before we ask “responsible for what?”     

Teen suicide and changing cause-of-death certification, 1953-1987.

This study examines whether the purported tripling in teenage suicides since the 1950s represents a real increase or is simply an artifact of the increased skill of medical examiners in distinguishing youth suicides from fatal accidents. This study examines firearms and poisoning deaths, which together account for 75% of all certified youth suicides, from 1953 through 1987, and concludes: (a) a past undercount of youth suicides is likely, (b) the increase in youth suicide that has occurred is less dramatic than reported and resembles increases in adult suicide, and (c) the suicide increase indicated among youths and adults occurred from 1964 to 1971 and has since stabilized.     

The effectiveness of family-based cognitive-behavior grief therapy to prevent complicated grief in relatives of suicide victims: the mediating role of suicide ideation

Grief interventions are more effective for high risk individuals. The presence of suicide ideation following suicide bereavement was examined to determine whether it indicates a high risk status. Using data from a randomized controlled trial (n = 122) on the effectiveness of cognitive-behavior therapy, the effect of suicide ideation on the effectiveness of grief therapy on the bereavement outcome at 13 months post loss was examined. Results show that suicide ideators more often have a history of mental disorder and suicidal behavior than non-ideators, and suicide ideation indicates a high risk for adverse bereavement outcome. Grief therapy likely reduces the risk of maladaptive grief reactions among suicide ideators. Therefore, suicide ideators may benefit from grief therapy following a loss through suicide.     

Assessing vulnerability to suicide.

Three hundred members of the American Association of Suicidology (30% of those who apparently received the questionnaire) participated in a survey in which case histories of two men who had committed suicide and two who had not were presented. Respondents assessed the vulnerability to suicide of each man, recorded their levels of confidence in their assessments, and provided information about themselves. The two men who killed themselves were rated as less vulnerable to suicide than the other two men, and as less vulnerable than one would expect by chance. Respondent characteristics that predicted to accuracy in assessing vulnerability were gender and level of involvement in research. The findings are discussed in terms of the limitations of theoretical models as well as characteristics of the respondents and nature of the study design.     

Current analysis of the Tarasoff duty: an evolution towards the limitation of the duty to protect.

In 1976, the Tarasoff case established a new legal duty to protect third parties from a psychiatric patient's foreseeable violence. After the Tarasoff case, courts expanded the scope and role of a clinician's duty to protect, sometimes in novel ways. Later interpretations of Tarasoff began to limit significantly the situations in which a duty to protect would attach. Recent Tarasoff-type cases in which courts have rejected the clinician's duty to warn suggest that Tarasoff is declining in significance. The advent of state statutes that codify the establishment and discharge of Tarasoff duty have contributed to a further limitation of the duty to protect. Lastly, when faced with the management of dangerous patients, we advocate for a thorough, well documented assessment of risk of violence as the best means for addressing concern about potential legal liability.     

Some conditions affecting the choice to cooperate or compete

Three experiments investigated conditions affecting the choice to cooperate or compete. Experiment I compared the effects first of an individual activity, then of a competitive task as an alternative to cooperation. For both comparisons, subjects could earn more by cooperating. Choice of competition, but not individual activity, was found to depend on the task choice contingencies. Competition predominated when both subjects could compete if either or both chose competition. Previously competitive pairs cooperated when both subjects could cooperate if either or both chose cooperation. Experiment II investigated the effects of differences in magnitude of the reinforcers for cooperating or competing. Choice between the two alternatives was manipulated in all pairs by varying reinforcer difference. Competition was chosen over cooperation only within the limits within which competition was potentially profitable. Experiment III replicated the findings of Experiment II using triads. Subjects in triads, however, were more likely to withdraw from the experiment. Thus, the data for pairs and triads suggest an orderly relation between reinforcer difference for cooperating or competing and task choice. Motivation of subjects to maximize relative gain by competing can be overridden by moderate reinforcer differences favoring cooperation.     

The normative and conceptual foundations of a clinical duty to protect

The continuing controversy surrounding the Tarasoff inspired duty to protect as developed by the courts and legislatures has not adequately weighed the jurisprudential foundations of such an obligation. The authors argue that the duty's misguided thrust of social control grounded in character and status seriously violates broad principles of political morality underlying the law of social control. They conceptualize an alternative--a clinical duty to protect--that coheres with these underlying values and the limits of professional abilities. They contend that any extra-clinical intervention on the part of the psychotherapist entails a role transformation requiring independent justification.     

Some sociopsychological factors in attempted suicide among urban black males.

This study tests three hypotheses relating to suicidal behavior among urban black males: that black consciousness and group cohesiveness will be lower and depression will be higher. Inner-city, young adult black males with a suicide attempt in the last 6 months, and matched controls were examined. Hypothesis was one supported; the other two received partial support. The validity of the theory of black self-hatred as the basic cause of suicidal behavior among blacks is questioned. Atwo-factor theory of suicide, focusing on forces moving the person away from suicide toward positive subgroup ties, is proposed.     

Clinical training and the duty to protect.

Given that the duty to protect is now a well established clinical and legal expectation, training in professional psychology should assist students in developing conceptual models for violence risk assessment and management. This report presents a training model incorporating recent advancements in risk assessment (such as the assessment of psychopathy), the need for basic legal understanding, and knowledge of specific risk management strategies. Additionally, academic and internship training programs in Michigan were surveyed by telephone about current training patterns. Preliminary results indicated program strengths in general awareness and training in risk factors. However, the data also suggested a need to formalize a faculty role in risk education, improve the training of students in relevant legal information, and establish coherent conceptual models of dealing with potential patient violence. It is argued that improving training of future professionals in this way will improve clinical practice, reduce legal liability, and improve public safety.     

Some considerations relating to the choice of an educational program

A random sample of 1098 new freshmen was cross-classified on sex and the extent to which the college major they selected was saturated with natural science and mathematics requirements. The responses of these students on 14 cognitive and 14 goal variables relating to the choice of an educational program were separately analyzed by means of the multivariate analysis of variance. The results of these analyses indicated that students entering natural science/mathematics programs tend to be oriented more towards the concrete and visible outcomes of an education and a career, e.g., training relevant to a career, an above average income, and success and recognition, than are students not choosing this type of program. Non-science students, on the other hand, value the interpersonal and usefulness to society outcomes of their educational and vocational pursuits. The results relating to the cognitive variables were less definitive, although students entering natural science/mathematics programs were more certain of successfully completing their educational program. Contrary to one of the major hypotheses the program groups did not differ with respect to the certainty of their choice of a college major. The results of this study were developed with a decision-making framework for choice of education and career.     

Genetic risk: the new frontier for the duty to warn.

Mental health professionals usually think of the "duty to warn" in the context of mental illness. However, two state appellate courts have endorsed a duty to warn when children of a patient may be at risk genetically for acquiring the disease of their parents. In these cases, the courts held that a physician's legal obligations extended beyond his or her patient to the patient's children. This article discusses these cases, as well as issues regarding implementation of such a duty and the implications for the physician-patient relationship in a health care environment that will be dominated increasingly by genetics issues. The article concludes that it is premature to apply a duty to warn to the treatment of mental illness and to concerns regarding future criminal behavior.