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SUICIDE RISK ASSESSMENT: YOU MAY SAVE A LIFE [ETHICS & RISK MANAGEMENT]

by William W. Deardorff, Ph.D, ABPP.


4 Credit Hours - $79
Last revised: 04/27/2016

Course content © Copyright 2012 - 2017 by William W. Deardorff, Ph.D, ABPP. All rights reserved.



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“There are two types of mental health therapists: those who have had a patient commit suicide and those who will”

 

 

COURSE OUTLINE

 

Introduction

Learning Objectives

Suicide in the United States

Malpractice in Mental Health Practice

Psychological Malpractice Defined

Suicidal Behavior and Malpractice

Risk Management versus Good Clinical Care

Therapeutic Risk Management

Framework for Suicide Risk Assessment and Management

Agreeing on Terms and Definitions

Potentiating Risk Factors

Warning Signs

Protective Factors

Tools of Suicide Risk Assessment

The Clinical Interview

Therapeutic Alliance

Countertransference

A Proposed Model for Assessment

Overview of Risk Factors Areas

Predisposition to Suicide

Stressors or Precipitants

Symptomatic Presentation

Presence of Hopelessness

The Nature of Suicide Thinking

Previous Suicidal Behavior

Impulsivity and Self-Control

Protective Factors

Actuarial Risk Assessment Instruments

What do I do with all of this Information?

Suicide Risk Level and Appropriate Responses

A Comment on No-Suicide Contracts

Alternatives to the No-Suicide Contract

Commitment to Treatment Statement

Crisis and Response Plan

Learning from our Mistakes

Lack of Communication between Therapists

Permitting the Patient or Relatives to Control Therapy

Therapist Avoidance of Issues Related to Sexuality

Ineffective/Coercive Actions Due to Therapist’s Anxiety

Not Recognizing the Meaning of Patient’s Communications

Untreated or Undertreated Symptoms

Documentation

Summary and Conclusions

Resources

Suggested Readings

References

 

INTRODUCTION

 

Seeing a patient with suicidal ideation or behavior is probably one of the most challenging and emotionally-charged areas in mental health practice.  It is also highly likely to occur on one or more occasions in a professional’s career.  In fact, the possibility of confronting a situation involving a suicide or suicide attempt is ever-present in practice.  Consider the following statistics presented in Table 1 (See Schwartz & Rogers, 2004; Tsao & Layde, 2007 and references for a review):

 

 

Table 1. Clinicians and Suicidal Patients

 

 

More than 50% of psychiatrists and 20% of psychologists report having lost at least one patient to suicide

 

Between 20% and 50% of psychiatry and psychology trainees report losing a patient to suicide during internship or residency

 

It is estimated that over 20% of counseling psychology trainees will be exposed to clinical situations involving suicide at some point during their training

 

In at least one study, 71% of mental health counselors in practice reported having had at least one client attempt suicide

 

In the same study, 28% had at least one client commit suicide

 

 

Effect on the therapist.  Patient suicides are among the most traumatic events in a clinician’s professional life.  Studies show that suicide is the number one source of stress for therapists (the emotional impact of a patient’s suicide is comparable to the death of a family member).

 

A malpractice suit, whether related to suicidal behavior or otherwise, can have a profound impact on the practitioner.  Simply going though the process can cause significant mental, emotional, financial and professional stress, even if the practitioner ultimately prevails.  In one study, investigators compared a group of physicians who had been sued with a group who had not.  The physicians who had been sued reported that they were significantly more likely to stop seeing certain patients, consider an early retirement, and discourage their children from entering the medical field (Charles et al., 1985).

 

 

Learning Objectives

 

 

Explain the concept of Therapeutic Risk Management

List four terms and definitions related to suicidality

List 6 key suicide risk factors, including potentiating factors and warning signs

Discuss therapists’ mistakes in assessing/managing suicidality

Discuss two examples of suicide risk assessment and appropriate responses

 

 

Suicide in the United States

 

The following Table presents an overview of US statistics related to suicide.  This is general data and more detailed information can be found on the NIMH and CDC web sites.  As will be seen, this information is important since it provides data that enters into the suicide risk assessment process.  Those in these static higher risk groups might be assessed more carefully and more frequently as part of mental health treatment.  For instance, according to this demographic data, an 85 year old male white male already has increased risk regardless of any other factors (that will be discussed in this course such as mental illness, substance use, impulse control, etc.).

 

 

Table 2.  Overview of U.S. Statistics Related to Suicide

 

 

In 2007, suicide was the tenth leading cause of death in the U.S., accounting for 34,598 deaths.

 

The overall rate was 11.3 suicide deaths per 100,000 people.

 

An estimated 11 attempted suicides occur per every suicide death.

 

Suicide was the seventh leading cause of death for males and the fifteenth leading cause of death for females in 2007.

 

Almost four times as many males as females die by suicide.

 

In 2007, suicide was the third leading cause of death for young people ages 15 to 24.

 

Of every 100,000 young people in each age group, the following number died by suicide:

Children ages 10 to 14 — 0.9 per 100,000

Adolescents ages 15 to 19 — 6.9 per 100,000

Young adults ages 20 to 24 — 12.7 per 100,000

 

Nearly five times as many males as females ages 15 to 19 died by suicide.

Just under six times as many males as females ages 20 to 24 died by suicide.

 

Older Americans are disproportionately likely to die by suicide. Of every 100,000 people ages 65 and older, 14.3 died by suicide in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population. 

 

Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000.

 

Of every 100,000 people in each of the following ethnic/racial groups below, the following number died by suicide in 2007:

 

Highest rates:

American Indian and Alaska Natives — 14.3 per 100,000

Non-Hispanic Whites — 13.5 per 100,000

Lowest rates:

Hispanics — 6.0 per 100,000

Non-Hispanic Blacks — 5.1 per 100,000

Asian and Pacific Islanders — 6.2 per 100,000

 

 

Beyond these general statistics, there are groups that may be of special interest to certain practitioners.  If you happened to work with a specific group in particular, it is very important to be familiar with the suicide rates for that group.  Just two examples include the military and adolescents.  In the military, one can see that the rate of suicide has steadily increased since 2001 (as compared to civilian statistics).

 us_military_suicides

Figure: Military suicide rate per 100,000

 

Another example is adolescents.  The following data is alarming given the fairly high percentage of high school students who considered attempting suicide, by grade level (2009 data from the Centers for Disease Control).  Any therapist working with this age group should certainly be aware of this information.

 highschool_considered_suicide

Figure: High school students – Suicidal ideation

 

These are just two examples.  The same data can be found for any other group that may be at a predisposed risk.  These all represent risk factors that must be assessed along with those presented in the individual situation.  If you specialize in working with any group that already has an elevated suicide risk (statistically) suicide risk assessment and closer monitoring takes on increased importance.

 

Malpractice in Mental Health Practice

 

Before discussing suicide risk assessment and management in detail, we will briefly review concepts related to liability and malpractice in mental health practice.  For a detailed review of this area, please see the Resources and Suggested Reading sections.  As discussed by Campbell and Lorandos in their classic series, Cross Examining Experts in the Behavioral Sciences (2001, pages 10-16),

 

“It is well stated in law, for example, that patients have (1) the right to psychotherapy treatment in the least restrictive environment, (2) the right to exercise informed consent to treatment alternatives, (3) the right to treatment that satisfies the standard of care, and (4) the right to expect that their therapist will act ethically”. 

 

When a practitioner violates any of these rights, he or she is at risk for a liability claim.  In the event of a malpractice action or licensing board complaint, the professional behavior of the practitioner will be judged against the standard of care for the specialty including such things as the ethical standards, guidelines promulgated by the appropriate professional agency and expert testimony regarding accepted evaluation and/or treatment procedures.  In various other BehavioralHealthCE courses, ethical issues in the practice of therapy are discussed.  Transgression of any of these ethical principles may be grounds for a liability action of some type; however, this course presents what might be considered the worst possible outcome to alleged professional misconduct: that of a liability claim.  Having an understanding of malpractice and licensing complaint issues can help the practitioner be “proactive” by practicing at or above the standard of care and implementing appropriate risk management techniques. 

 

Ideally, malpractice law serves three important social functions. First, it protects the public from professional wrongdoing by providing aversive consequences for misconduct. Second, it transfers the “loss” from one party to another whom more so deserves to pay. Third, it distributes the cost of a professional’s negligent conduct across the profession at large through insurance premiums. In these ways, the threat of malpractice provides constant pressure on professional communities to self-regulate and self-scrutinize while giving the public a mechanism to recompense when this does not occur.

 

As evidenced by spiraling medical costs, partially related to increased malpractice litigation, it appears that the social function of malpractice law has been disrupted by consumers’ propensity to initiate litigation. This may either be where negligence has occurred or, increasingly, where no negligence is ultimately determined. It might be speculated that skepticism about health care treatment and heightened angry affect over medical costs combined with an increase in the number of attorneys per capita have fostered the likelihood of malpractice litigation occurring. Costs are incurred in such legal actions, even if the professional is exonerated. In the vast majority of cases, the case will be settled out of court in an effort to avoid the higher expenditures regardless of whether there was misconduct, thus reinforcing suit-filing behavior independent of the merits of the case. There is a societal cost for such freedom of action, and this is ultimately passed back to consumers.

 

Mental health professionals have not been threatened by malpractice in the same magnitude as physicians (National Practitioner Data Bank, NPDB, 2007). There are at least two reasons thought to be responsible for this finding: (1) The nature of the therapist-patient relationship helps to inhibit such action.  Even in the medical field, studies have demonstrated that the likelihood of a patient initiating a malpractice action is related to the doctor-patient relationship (Moore, Adler, & Robertson (2000). (2) In the mental health area it is difficult to prove the four malpractice standards to be described subsequently (Bernstein and Hartsell, 2004). However, along with a greater public awareness of mental health practitioners’ professional behavior, malpractice claims in mental health practice are on the increase-a trend that is continuing (NPDB, 2007).  As concluded by Campbell and Lorandos (2001), “In a very real way, mental health professionals have been ‘discovered’ by malpractice attorneys in the last 25 years” (page 10-80). 

 

Psychological Malpractice Defined

 

Malpractice claims fall within two broad categories:  a professional error of commission (including misfeasance and malfeasance) or omission (nonfeasance).  In the first category, there is a claim that the practitioner carried out his or her professional duties improperly or in a fashion inconsistent with the profession’s standard of care.  This might include such things as incorrect or injurious treatment, failure to diagnose, breach of confidentiality, abandonment, etc.  There is a difference between misfeasance and malfeasance.  Misfeasance is defined as, “The commission of a proper act in a wrongful or injurious manner, or the improper performance of an act that might have been performed lawfully” (Reamer, 2003, p. 4).  Examples include inadvertently disclosing confidential information or inadequate informed consent procedures. Malfeasance is defined as, “the commission of a wrongful or unlawful act” (Reamer, 2003, page 4).  Examples include sex with a minor, embezzlement, physical assault, wrongful death, and violation of a patient’s civil rights.  

 

Malpractice suits have been generally founded in tort or contract law as opposed to criminal law. The difference is that the former pertains to acts damaging to a person whereas the latter applies to transgression against society. To make a successful case of malpractice, the plaintiff must prove, by a preponderance of evidence, the following four elements (See Table 3):

 

 

Table 3. Elements of Malpractice  

 

 

that the defendant/practitioner owed a “duty” to the patient,

 

that the defendant/practitioner’s behavior fell below the acceptable standard of care or that the “duty” owed to the plaintiff was breached,

 

that an injury was actually sustained by the plaintiff, and

 

that the defendant/practitioner’s act or omission was the proximate cause of the plaintiff’s injury.

 

 

Each element is discussed subsequently, with its implications for professional practice. Each of these must be demonstrated by a preponderance of evidence. They are summarized by the 4D mnemonic: Dereliction of-Duty-Directly causing-Damages.

 

Owing a Duty to the Patient

 

The first of these allegations, that the practitioner owed a duty to the patient, is usually the easiest to prove. This basically involves proving that a professional relationship existed between the practitioner and patient; such things as a treatment contract, bill for services, or chart notes, are sufficient evidence. Related to this contract, when a professional accepts a case, he or she owes a duty to possess the level of skill to treat commensurate with that possessed by the average member of the profession in good standing in the community. This is considered the prevailing standard of care in the profession.   Furthermore this skill and learning must be applied with reasonable care.

 

Proving a Breach of Duty

 

To prove a breach of duty, the plaintiff must show that the practitioner’s behavior fell below the acceptable standard of care.  This might include not having proper knowledge to treat or that the knowledge was misapplied.  Of course, proving a breach of duty requires that the prevailing standard of care be fairly clearly established.   The standard of care is an important concept not only relative to liability claims but also in guiding one’s practice.  Unfortunately, many therapists do not have an understanding of the concept.  The standard of care is the usual and customary standard of practice in the community for the same profession or discipline. The standard of care is a complex construct and is not contained in any textbooks.  Rather, it is derived from six concepts (See Table 4):

 

 

Table 4. Six Concepts of Standard of Care

 

 

Statutes: Each state has its own statutes (e.g. child abuse reporting laws) and a professional’s behavior will be judged against those.

 

Licensing Board Regulations:  Each state has its own set of extensive licensing board regulations that govern such things as continuing education, licensing and supervision.

 

Case Law: Case law is one of the most important aspects of standard of care.  Tarasoff is an example of case law defining a standard of care. 

 

Ethical Codes:  Ethical codes are an important, but controversial, aspect of standard of care.  Even though professional ethical codes technically only apply to members of the respective organization, in most liability situations they are also applied to non-members.  Since professional ethical codes are ambiguous and unclear about what kind of behaviors are mandated or prohibited (unlike case law and regulations), they are easily misinterpreted and used against the practitioner in legal proceedings.  For instance, even though the APA Ethics Code (2002) specifically states that, “The Ethics Code is not intended to be a basis of civil liability” (Introduction and Applicability) and “Whether a psychologist has violated the Ethics Code standards does not by itself determine whether the psychologist is legally liable in a court action, whether a contract is enforceable, or whether other legal consequences occur” (Introduction and Applicability), they are often used for just that purpose in liability claims (either licensing board complaints or malpractice).  This is similar to National Association of Social Workers Code of Ethics which states, “Violations of standards in this Code does not automatically imply legal liability or violation of the law.  Such determination can only be made in the context of legal and judicial proceedings” (NASW, 2008). 

 

Consensus of the Professionals:  The standard of care is also established by expert witness about the consensus of other professional practicing in the same discipline.  This can be extremely difficult to establish in a field such as psychotherapy.  However, as will be discussed subsequently, the publication of evidence-based practice guidelines, which is becoming very common, certainly helps establish consensus of professionals.   

 

Consensus in the Community:  The standard of care is also derived from community norms.  As such, the standard of care might be different across various contexts such as working with specific religious groups or cultures, practicing in the military environment or Veteran’s Affairs facilities, and services in a rural area.

 

 

Outrageous actions such as beating a patient (Hammer v. Rosen, 1960), engaging in sexual contact with a patient as part of treatment (Roy v. Hartogs, 1975) or nontraditional improper treatment resulting in injury can provide a prima facie case of malpractice. One of the most widely publicized instances of improper and non-traditional treatment was a Colorado case in which a ten-year-old girl died of suffocation as part of “rebirthing” treatment for an attachment disorder.  The “treatment” included wrapping the girl in a blanket to provide the rebirthing experience.  The girl was unable to breathe and died of asphyxiation.  The treating social worker was convicted of death resulting from reckless child abuse and sentenced to 16 years in prison (See Reamer, 2003 for a review). 

 

Other than cases of this nature, proving a breach of duty has, historically, been difficult in an ambiguous practice such as psychotherapy; however, this situation is clearly changing.  With advancements in psychological research there has been a movement towards identifying empirically supported (“evidence-based”) treatments and using those criteria to select interventions for particular conditions (Chambles and Ollendick, 2001).  Many of these evidence-based guidelines are summarized in such texts as, Handbook of Assessment and Treatment Planning for Psychological Disorders (Antony and Barlow, 2002), A Guide to Treatments That Work, 2nd Ed. (Nathan and Gorman, 2002) and Social Work in Mental Health: An Evidence Based Approach (Thyer and Wodarski, 2007).  As we shall review, there are many practice guides relative to suicide risk assessment and management. It is not inconceivable that future liability actions will rely on published guidelines to help establish the standard of care against which practitioners’ actions will be judged.  However, national organizations such as APA have adopted policies on evidence based practice that, embrace a broader set of constructs than lists of empirically supported treatments.  As in medicine, evidence based mental health practice requires the integration of the best research evidence with the clinical expertise of the clinician and the values/perspectives of the patient.

 

Related to the area of suicide risk assessment and management, there are now multiple “Practice Guides” that have been published (See Resources).  These Guides are based on evidence-based clinical research and make clear suggestions for real-world practice.  In the case of a malpractice claim against a practitioner for an issue related to suicidality, these Guides can help establish a standard against which the clinician’s behavior will be judged.

 

As reviewed previously, the standard of care against which the practitioner’s behavior is judged in malpractice litigation is established, in part, by expert testimony (e.g. consensus of the professionals). In the past, it has been difficult to get members of a profession to testify against one another (Markus, 1965).  Currently, this is less problematic since the courts abandoned the “locality rule” (which required the expert witness to be from the same geographical area as the defendant/practitioner).  This change in court practice has had two important implications. First, it has successfully diminished the “conspiracy of silence” related to expert witness testimony. Second, it means that a reasonable standard of care for psychological practice may be set at the national standard instead of a community standard and that the practitioner may have malpractice liability where local standards are below those of the national level.

 

Establishment of Injury

 

The third element the plaintiff must demonstrate is that harm or injury was suffered. Where physical harm has been sustained, it is easier to establish injury and specify monetary compensation; where the injury is emotional or psychological, it can be very difficult to establish compensation amounts. For instance, in an example of an injured worker who had a dominate arm amputation, it would be relatively easier to estimate compensation on the basis of medical costs, physical disability, lost wages, and pain-suffering than in a psychological injury case.  Expert witness testimony is often required to help objectify a psychological injury.  In an injury related to a suicide attempt, or a completed suicide attempt, the injury is much more straightforward.  

 

Proving Proximate Cause of Patient’s Injury

 

The last allegation to prove is that the plaintiff’s injury was either directly caused by the practitioner’s action or a reasonably foreseeable consequence of such behavior. Where the practitioner’s behavior is not outrageous, proving this essential causal link between professional conduct and mental injury can be very difficult. However, if the injury is physical, proof is much easier.  In the area of suicide risk assessment and management, the injury (due to either completed suicide or an unsuccessful attempt) is physical.

 

Suicidal Behavior and Malpractice

 

Since most state laws impose a duty to protect and prevent suicide, liability for wrongful death can potentially be established in numerous ways.  These can be seen in Table 5.

 

 

Table 5. Potential Areas of Liability Related to Suicide

 

 

Failure to take appropriate and sufficient action to prevent death

Failure to follow the rules and procedures of a setting

Failure to provide an acceptable standard of care

Errors in judgment about whether to confine a patient

Negligent assessment and diagnosis

Failure to document activities performed on behalf of the patient

 

 

According to Shapiro and Smith (2011), malpractice claims related to suicide comprise 4% of all complaints experienced by the American Psychological Association Insurance Trust (APAIT).   Of course, for the practitioner wishing to avoid “Failure” behavior in one of these areas faces multiple challenges.  First, there is no single, legally accepted standard of care related to assessing and managing suicidal patients.  In most legal cases involving suicide attempts or suicides, two questions are addressed: 

 

(1) what was the actual foreseeability of the behavior? and

 

(2) were the actions of the practitioner relative to that foreseeability reasonable, including both assessment and prevention?

 

Although this seems straightforward, it is quite difficult relative to suicide behavior.  This is due to the fact that reliably predicting a low base-rate phenomenon such as suicide is not possible.  In other words, because completed suicide (or even suicide attempts) occurs so infrequently, a clinician would actually be correct much more of the time if he or she predicted that a patient would not complete the behavior regardless of the clinical presentation. This creates somewhat of a paradox and probably leads to complacency on the part of many therapists.  In the vast majority of cases, if the clinician simply “does nothing” the prediction (by default) of no suicidal behavior will be correct. However, in the infrequent instance when something does happen, the results can be devastating.

 

The inability to predict suicidal behavior does not mean that important risk factors that place a patient at increased risk have not been identified in the research.  Therefore, the therapist’s task is not to predict suicide behavior but to assess and recognize when a patient has entered a heightened state of risk, and to respond appropriately.  In a malpractice case, the foreseeability probability will be determined retrospectively by the legal system.  The legal system will determine if the heightened state of risk was adequately assessed and identified, and appropriate measures taken.  The clinician’s behavior must reflect “knew or should have known” at the time of the occurrence. 

 

The therapist, under the law, is not required to do something that is not possible – e.g. being absolutely precise in predicting suicidal behavior.  Accurately predicting suicide behavior is extremely difficult even when using the most comprehensive evaluation methods.  However, the clinician is expected to behave consistently with the community standard of care.  Therefore, if the therapist does a careful evaluation for suicidality that is consistent with professional practice, concludes that the risk is low and the behavior not foreseeable, and the patient commits suicide, there is no liability (A. R. Smith et al., 2008). Given the above, the question is,

 

“What constitutes suicide assessment and management that is consistent with the professional community standards?”

 

Simply using one’s “clinical experience” to decide a patient’s level of suicide risk is not adequate.  As discussed by Simon (2006),

 

“Clinical experience, unaided by evidenced-based research, can be idiosyncratic, insufficient, uninformed, or just plain wrong when applied to complex, fact-specific suicide cases” and “Substandard suicide risk assessments often rely on clinical experience alone” (p. 276). 

 

Anyone who has been in a role of a defendant or e xpert witness knows that,

 

“Lawyers make short work of clinical experience” (Simon, 2006). 

 

The suicide assessment and management methods should have some construct validity and rationale for use based upon the evidenced-based literature.  One aspect of this is clinical experience, in addition to well-validated methods of assessment and intervention.  Otherwise, the therapist is not providing his or her client the best possible care, and introducing risk (clinical and legal) into the situation (See Table 6).

 

 

Table 6. Actual Claims: Suicide Attempts or Completed Suicide

 

 

Failure to provide proper assessment and management in high volume patient settings

Failure to construct a comprehensive treatment plan

Failure to perform comprehensive suicide risk assessment

Failure to document suicide risk assessments

Failure to obtain past treatment records

Failure to make a rational diagnosis on the basis of history and evaluation

 

 

Risk Management versus Good Clinical Care

 

Practitioners often take offense and resent the idea of focusing on “risk management”.  They complain that it is a “defensive” approach to practice that gets in the way of good clinical care.  Clearly, the law has come to play a pervasive role in mental health practice.  The therapist-client relationship is no longer defined just by the therapist and the client.  It is also shaped by many extra-therapy variables such as insurance coverage, managed care, and, of course, the legal system.  As discussed by Simon and Shuman (2009), knowledge of the legal regulation of mental health providers that informs clinical practice is no longer optional for the practitioner.

 

“The requirements of the law must be integrated with best practices to achieve optimal therapeutic benefits.” (Simon and Shuman, 2009, p. 155).

 

For most practitioners, suicide assessment is an anxiety-producing experience and it has been suggested that they may respond in one of two ways, neither of which is desirable (Bryan and Rudd, 2006).  On the one hand a clinician may choose to be overly cautious taking an attitude of “better safe than sorry”.  In these situations, ongoing suicide risk assessment may become onerous with a bias towards overestimating suicide risk.  This can be deleterious to the treatment process, potentially deprive the patient of certain rights, and squander limited clinical resources.  On the other hand, a practitioner might choose to take a dismissive or minimizing attitude toward obvious signs of suicide risk.  This approach is often correlated with a substandard risk assessment and management.  It also creates a situation in which good clinical care is not provided; patient safety is put in jeopardy; and clinician liability increased.  

 

In mental health practice, the only way to reduce the risk of a malpractice suit to zero, is to not see patients.  Short of this most drastic “defensive” measure, the goal of risk management is to reduce the likelihood of a successful malpractice suit or to maximize the success of a legal defense should one occur.  As a means of conceptually balancing the goals of “risk management” and “good clinical care”, Simon and Shuman (2009) introduce the concept of therapeutic risk management.  Although they develop their concept relative to the practice of psychiatry, it is certainly applicable to any mental health discipline (See Table 7).

 

 

Table 7.  Characteristics of Therapeutic Risk Management

 

 

Therapeutic risk management “assumes that, in addition to clinical competence, there is an optimal therapeutic accord to be found in each case which demands a working knowledge of the law regulating the practice of psychiatry” (or any other mental health discipline).

 

Therapeutic risk management is an essential part of good clinical care.

 

Therapeutic risk management supports the patient’s treatment and therapeutic alliance.

 

Therapeutic risk management avoids defensive practice of dubious benefit (which can actually invite a malpractice suit).

 

Therapeutic risk management keeps the practitioner focused on the patient and good clinical care; whereas, malpractice risk management keeps the therapist focused on the therapist, possibly to the detriment of patient care.

 

 

As they discuss, successful resolution of clinical-legal dilemmas requires an understanding of the legal process that helps clinicians provide good patient care and to avoid counterproductive defensive practices.  Since the law derives its requirements from professional practice in the form of community standards, good clinical practice and appropriate risk management can be very complimentary rather than at odds with one another. 

 

Simon and Shuman (2009) have developed a categorization of risk management or “defensive” practices that may or may not constitute “therapeutic risk management” and may or may not be consistent with good clinical care.  Having an understanding of these categories can help the therapist develop a therapeutic risk management strategy that is consistent with good clinical care.  As they state, when defensive practices direct rather than support clinical decision-making, this can be deleterious to the therapist-patient relationship, the treatment process, and the ultimate outcome. 

 

Defensive practices can be categorized as pre-emptive or avoidant and sub-classified as appropriate or inappropriate (See Table 8).

 

 

Table 8.  Therapeutic Risk Management and Defensive Practices

 

 

Pre-emptive, inappropriate – An example might be hospitalizing a patient with a mild-to-moderate risk of suicide that, according to the evidenced-based literature, might be better managed as an outpatient.  Another example might be the therapist becoming so obsessed with practicing “defensively” that a lengthy suicide risk questionnaire is given to the patient on every visit, almost to the exclusion of doing any real treatment.

 

Avoidant, inappropriate – This might include finding a reason to terminate a patient from treatment at the first mention of any suicidal ideation, even if mild and no other risk factors.  The therapist might pursue the termination even though the patient is making good progress.

 

Pre-emptive, appropriate – This includes documenting suicide assessment and one’s formulation of risk, including management strategies. It includes taking appropriate action when necessary that is pre-emptive to completing suicidal behavior such as ongoing treatment, or more aggressive intervention when necessary (e.g. involuntary admission, etc.)

 

Avoidant, appropriate – The therapist “avoids” defensive practices of dubious benefit especially when these will very likely interfere (or even preclude) good clinical care.  An example includes not giving a patient onerous and lengthy suicide risk questionnaires at each visit but instead focusing on good clinical practice while doing reasonable monitoring of risk.  

 

 

It should be noted that good clinical care is not synonymous with therapeutic risk management.  As discussed by Simon and Shuman (2009), good clinical care is necessary but not sufficient in reducing malpractice risk.  They give the example that good clinical care respects the right of a patient to refuse treatment.  In these cases, the therapist might attempt to enhance the therapeutic alliance so that proper treatment (good clinical care) can be provided.  But consider the situation in which a therapeutic alliance cannot be established, the patient starts to refuse treatment, and a crisis situation ensues (e.g. increased suicidality).  Clinical practice might dictate continuing to attempt to treat the patient and resolve the problem.  However, at some point, the legal standard of care will become preeminent and the patient should be provided treatment regardless of consent (e.g. involuntary hospitalization).  At this point, the provider has moved from clinical care alone to therapeutic risk management.   As the authors discuss, in some situations, the legal standard of care does not require the therapist to adhere to best practices or even provide good clinical care to the patient.  

 

Framework for Suicide Risk Assessment and Monitoring

 

The following framework is adapted from the Suicide Risk Assessment Guide: A Resource for Health Care Organizations (HCO Guide; Perlman et al., 2011); Advances in the Assessment of Suicide Risk (Bryan and Rudd, 2006),  Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (APA, 2003) and other sources (See resources and references).  As discussed in the HCO Guide (p. 65):

 

“Suicide risk assessment needs to be thorough, person-centered, and simple.  It needs to incorporate multiple approaches to ascertain a person’s level of distress and risk of suicide”

 

The process of suicide risk assessment is just as important as the assessment tool(s) chosen for use.  The clinician, depending on a number of factors, will decide which approach or combination of approaches works best in his or her particular setting and patient population.  The HCO Guide, based on the extant research in the area and interviews with experts, suggests that clinicians should:

 

Beware of warning signs, potentiating risk factors, and protective factors

Use good clinical judgment as well as other information about the patient

Document findings

Appropriately monitor the patient

 

Agreeing on Terms and Definitions

 

When discussing suicide risk assessment and management, it is important to be able to agree on terms and definitions to insure accurate communication (Rudd, 2008; Rudd et al., 2006).  In some cases, patients with different characteristics will need to be assessed and managed very differently (e.g. history of suicide attempts versus instrumental suicide-related behavior versus self-harm).  Currently terminology can be found in Table 9.

 

 

Table 9. Definition of Terms Related to Suicidality

 

 

 

Suicide – an intentional, self-inflicted act that results in death.  Synonymous with “completed suicide”

 

Suicide attempt with injuries – An action resulting in nonfatal injury, poisoning, or suffocation where there is evidence that the injury was self-inflicted and that the person intended at some level to die.

 

Suicide attempt without injuries – A potentially self-injurious behavior with a non-fatal outcome, for which there is evidence that the person intended at some level to kill himself/herself.

 

Instrumental suicide-related behavior – Potentially  self-injurious behavior for which there is evidence that the person did not intend to die (zero intent) and the person wished to use the appearance of intending to commit suicide in order to attain some other end (seek help, punish others, receive attention).  Instrumental suicide-related behavior can occur with injuries, without injuries, or with fatal outcome (accidental death).

 

Suicide Threat – Any interpersonal action, verbal or non-verbal, stopping short of a directly self-harmful act, that a reasonable person would interpret as communicating or suggesting that a suicide act or other suicide-related behavior might occur in the near future.

 

Suicidal Ideation – Any self-reported thoughts of engaging in suicide-related behavior.

 

Self-harm – an intentional and often repetitive behavior that involves the infliction of harm to one’s body for purposes not socially condoned and WITHOUT suicidal intent.

 

 

When completing a suicide risk assessment it is important to distinguish between some other key concepts beyond defining terms.  For instance, some risk factors are associated with suicide (potentiating risk factors and/or chronic risk factors) and some are known to actually increase the risk of suicide (acute or warning signs).  Potentiating or chronic risk factors tend to be static and do not change much over time.  These risk factors do not necessarily indicate that a person is at increased risk for an imminent attempt. On the other hand, acute or warning signs are dynamic and are those factors that suggest suicidal behavior may be set in motion in the very near future. Warning signs may suggest the heighten risk of suicide in the short term even in the absence of potentiating/chronic risk factors.  Alternatively, potentiating/chronic risk factors may predispose a person to a chronic heightened risk of suicide in which warning signs may not be present (but when they emerge, may represent an emergent situation).  The interplay between potentiating risk factors and warning signs will be discussed further after the presentation of the specific factors (See Table 10).

 

 

Table 10.  Key Concepts in Suicide Risk Assessment and Management

 

 

Potentiating Risk Factors – these include such things as unemployment, financial difficulties, social isolation, prior trauma or abuse, previous suicide behavior, chronic mental illness, physical illness, etc.  The factors tend to be more static (not rapidly changing) and can form the basis of a chronic suicide risk level (low to high).

 

Warning Signs – are factors that may set into motion the process of suicide in the short term.  These may be conceptualized as occurring in the acute phase of suicidality. These can occur as an exacerbation of a chronic suicide baseline.  

 

Protective Factors – these are factors that have been associated with a reduced risk of suicide.  Although risk factors are more strongly associated with suicidality, interventions often focus on enhancing protective factors while reducing risk factors.

 

 

In addition, it is important to distinguish between chronic suicidality and acute suicidality, since these patients must be managed differently.  Chronic suicidality presents differently from acute suicidality, and the treatment approach is different.  For instance, hospitalization of the chronically suicidal person (absent significant warning signs) has little value in preventing suicide and may have a negative effect (repeated admission, destruction of therapeutic alliance).  The chronically suicidal patient may present symptoms over the long term (e.g. months or years) but still must be assessed and monitored for emergence of acute suicidality (warning signs).  Treatment of the chronically suicidal patient often includes addressing the underlying reasons for the symptoms (e.g. personality disorder, as a means to express distress). In these cases, the clinician must often tolerate the suicidality over extended periods and provide treatment in the least restrictive setting (e.g. outpatient) even when there is slightly elevated risk.  

 

TOOLS OF SUICIDE RISK ASSESSMENT

 

The assessment of suicide risk is most often based upon the identification and appraisal of potentiating/chronic risk factors, acute/warnings signs AND protective factors that are present.  The assessment should always include a clinical interview and collection of other important information as appropriate (past treatment records, information from family, etc.).  The clinical interview can be augmented by risk assessment instruments.  As this material is presented, the reader may walk away with the feeling that an appropriate suicide risk assessment is an onerous, lengthy, complex task and might take the better part of a full day to complete.  Actually, much of the information that will be reviewed should be collected as part of any initial clinical interview and is not unique to suicide risk assessment.  This presentation discusses how to think about, and organize, information that is routinely collected, along with adding some key questions unique to this area.  Subsequently, some suggestions for documentation of the risk factors assessment will be discussed.

 

The Clinical Interview

 

Therapeutic alliance. Most clinicians in practice probably use the clinical interview (and follow up interviews or treatment sessions) as their primary source of data in completing a suicide risk assessment.  One of the key elements of an effective clinical interview (assessing suicide risk factors or anything else), is rapid establishment of the therapeutic relationship.  In some settings, the suicide risk assessment may be vulnerable to becoming automated and focus solely on triage of services or gathering the necessary information as quickly as possible (checking off the boxes).  Therefore, the primary principle for maintaining a person-centered risk assessment is the establishment of a therapeutic relationship (American Psychiatric Association, 2003).  This relationship is based on utilizing the clinical skills with which the reader should be familiar (e.g. active listening, trust, respect, genuineness, empathy, etc.). 

 

Patients can usually sense when a clinician is comfortable with the topic of suicide.  At that point, the patient may feel safe enough to share important information about their suicidality, especially warning signs that suggest an attempt is imminent.

 

Countertransference and being comfortable with the topic. In addition to quickly establishing a therapeutic relationship, it is also important that the clinician be comfortable asking about suicide risk and protective factors, as well as having insight into any countertransference issues that might arise (e.g. feeling the patient “uses” suicide ideation or gestures in a manipulative fashion, etc.).  Some of the countertransference issues that arise in the therapist might include (See Table 11):

 

 

Table 11.  Countertransference Issues

 

 

Anxiety-Avoidance:  I don’t accept suicidal patients into my practice

 

Hopelessness: If a person is really intent on killing himself, there is nothing one can do to stop him

 

Contempt:  If I were him, I would kill myself too

 

Disdain:  It wasn’t a serious attempt – just a manipulative gesture

 

Hostility: Maybe he will get it right next time.

 

 

Another countertransference issue actually relates to the goal of the suicide risk assessment.  As discussed by Shea (1998):

 

“It seems pertinent to raise a countertransference issue that many interviewers do not like to admit, but one which I think is present in most of us.  Namely, if we uncover serious suicidal ideation, we are potentially creating a mess for ourselves.”

 

This type of countertransference leads the therapist to ignore comprehensive assessment of suicide risk factors in the first place and minimize their significance, if found, in the second place.

 

A Proposed Model for Assessment

 

Bryan and Rudd (2006) present a model that is based primarily on the clinical interview.  An overview of their model, supplemented by other literature, will be presented here.  There are a number of areas that have been empirically shown to be important to risk assessment and should be included as part of the clinical assessment. 

 

 

Table 12. Suicide Risk Assessment Areas

 

 

Predisposition to suicidal behavior

Previous history of psychiatric diagnosis

Previous history of suicidal behavior

Recent discharge from inpatient psychiatric treatment

Same-sex sexual orientation

Male gender

History of abuse

Identifiable precipitants or stressors

Significant loss (financial, interpersonal, identity)

Acute or chronic health problems

Relationship instability

Symptomatic presentation

Depressive symptoms

Bipolar disorder

Anxiety

Schizophrenia

Borderline and antisocial personality features

Presence of hopelessness (severity/duration)

Nature of suicidal thinking

Current ideation, plan, availability of means

Lethality of means

Active suicidal behavior, Explicit suicide intent

Previous suicidal behavior

Frequency and context

Perceived lethality and outcome

Opportunity for rescue and help seeking

Preparatory behaviors

Impulsivity and self-control

Subjective self-control

Objective control (substance use, impulsivity, aggression)

Protective Factors

[These are presented in Table 16]

 

 

When assessing suicide risk, it is important to distinguish between explicit and implicit intent.  Explicit or subjective intent is the patient’s stated intent, or what the patient actually says during the interview (e.g. “Even though I have thought about killing myself, I would never do it”). Implicit or objective intent is estimated by the patient’s current and past behaviors, as well as his or her expressed understanding of the lethality of the method chosen (e.g. past attempts, means available, low impulse control, substance use, multiple stressors, lethal means available).  When the clinician notices a discrepancy between implicit and explicit data, this should be pointed out to the patient and discussed.  An example might be a person who says, “I would never really commit suicide……those weren’t real attempts in my past” while the data indicate likely history of lethal attempts, low impulse control, substance use, a gun in the house, lack of social support, etc.

 

Bryan and Rudd (2006) suggest using a 1-to-10 rating scale as a useful method when doing a suicide risk assessment.  This has several advantages including:

 

  • providing the patient with a method to quantify and clarify a response
  • permitting comparisons over time and treatment sessions
  • providing a method for the therapist and patient to identify change
  • potentially improving communication when more than one clinician is involved

 

Examples of questioning using this method include the following (adapted from Bryan and Rudd, 2006, p. 190).  Each of these types of question is following by …..on a scale of 1 to 10 with 1 being ______ and 10 being ______”.  The therapist can decide on the anchors for each question and which direction equals a more or less severe direction.

 

How would you rate the severity of your hopelessness?

How would you rate your intent to kill yourself right now?

How would you rate the severity of the thoughts to kill yourself?

How would you rate your hopefulness about the future? 

How would you rate your ability to seek help if you feel very suicidal?

 

Acute versus chronic risk.  As discussed previously, it is important to keep in mind acute versus chronic risk factors.  In general, chronic risk factors are similar to what was termed potentiating factors previously.  These factors tend to be static.  As will be reviewed in more detail later, each individual will have a chronic suicide baseline level which represents a compilation of the predisposing factors and ongoing issues.  The baseline is the state in which the patient is going to be “as good as it gets.”  Against that background, patients will show acute exacerbations preceded by the warning signs.  These factors are considered “dynamic.”

 

Overview of Risk Factors Areas

 

The following is an overview of the risk areas presented in Table 12.  It is beyond the scope of this course to present the detailed and extensive research relative to each area.  For comprehensive review and practice guidelines the reader is referred elsewhere (Suicide Risk Assessment Guide Ontario Hospital Association, 2011; 122 pages; Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors, 2003; 123 pages).

 

Predisposition to Suicide 

 

Predispositions to suicide are stable (static) factors and should be assessed as part of any initial interview.  These include previous history of psychiatric diagnoses, previous history of suicidal behavior, and history of abuse.  Research suggests that a person is at a higher suicide risk within one year of release from inpatient psychiatric treatment. Even though warning signs may not be imminent, this represents a “chronic” risk factor. The other risk factors listed in Table 12 interact in somewhat complex ways and it is not a simple additive effect (e.g. more factors equals greater risk).  For the clinician in practice, taking note of these potential factors, within the context of all other factors assessed, is important.

 

Stressors or Precipitants

 

There are multiple issues that might be considered a stressor or precipitant to suicidal behavior.  Some of these have been more consistently demonstrated in the literature and some will be unique to the individual patient.  The use of the 1-to-10 rating method can give the clinician a rapid method for assessing just how stressful the issue is perceived by the patient.  As listed in the Table, a stressor might include any significant loss such as financial (job, investments, lawsuit), interpersonal (marriage, other relationship, death of loved one), health problems (acute or chronic), or family instability (change in family structure for any reason such as divorce, loss of child custody, etc.).

 

Symptomatic Presentation

 

Research has demonstrated a significant risk factor for suicide in the presence of a major mood disorder, especially during the depressive phase.  As discussed by Bryan and Rudd (2006), and in this course earlier, because the base-rate of the behavior is so low (less than 1% of individuals who have an affective disorder commit suicide) it is extremely difficult for a practitioner to successfully identify which individuals with affective disorders are high risk.  Research has identified some of the more potent predictors related to affective disorder symptoms. These include hopelessness, low self-esteem, and substance abuse/dependence. Relative to bipolar disorders, the risk is higher early in the course of the disorder.  For schizophrenia, the lifetime risk of suicide is about 4% and peaks during young adulthood.  Relative to personality disorders, the categories of borderline and antisocial appear to carry higher risk.

 

Presence of Hopelessness

 

A majority of suicidal patients report hopelessness (and gaining relief from it) as a primary motivator for the suicidal behavior.  Therefore, the presence of hopelessness, along with its severity and duration should be carefully assessed.

 

The Nature of Suicidal Thinking

 

Although clinicians are often not comfortable discussing suicidal thinking with patients, it is extremely important to assess it in an open manner.  Clinicians may have a tendency to avoid the topic thinking that “If I don’t bring it up, it won’t be an issue”.  Suicidal thinking should be assessed for the following dimensions (See Table 13):

 

 

Table 13.  Assessment of Suicidal Thinking

 

 

Frequency   

 

 

How often do you think about suicide?

 

 

Intensity

 

 

How would you rate the intensity of your thoughts?

 

 

Duration    

 

 

How long have you had these thoughts?

 

 

Specificity and plans

 

 

Have you thought about how, when and where to kill yourself?

 

 

Availability of means

 

 

Do you have access to a [gun, pills]?

 

 

Active behaviors

 

 

Have you taken any steps to prepare for your suicide? [note, finances in order, other]?

 

 

Explicit intent

 

 

When you are thinking about suicide what helps you feel better, more hopeful?

 

 

Deterrents 

 

 

What stops you from killing yourself?

 

 

To enhance the therapeutic alliance and decrease resistance, it can be useful to discuss more remote suicidal episodes first and then move toward the present.  The clinician might also need to take into account cultural issues and this line of questioning.  Some cultures maybe more or less open to discussing suicide issues.  As discussed by Bryan and Rudd, “hidden” suicide “ideators” exist in all groups and it is important to complete a full risk assessment to identify them.  As the authors conclude, “We recommend that direct probing for suicidal intent be practiced as a general rule, not as a special circumstance” (p. 194).

 

 

Table 14. Previous Suicidal Behavior

 

 

Frequency

 

How often have you attempted to kill or hurt yourself?

 

 

Context

 

What was going on during those times?

 

 

 

Perceived Lethality  

 

Why did you choose that method? Did you think it would be successful?

 

 

Opportunity for Rescue  

 

 

Did you know ____ would rescue you?

 

 

Identifiable Preparation for Death

  

 

Have you been putting your will together?  Have you been giving away items?

 

 

Previous Suicidal Behavior

 

It is important to not only assess previous suicide behavior but also the various dimensions for each attempt (See Table 14). In this process, it is important to distinguish between previous attempts (with and without injuries) and instrumental suicide-related behavior for each instance.  This will give the clinician a very good idea of increased risk especially when “chronic risk” is identified. Research has demonstrated increased future risk is associated with number of previous actual attempts and the method of previous attempts.  One must also pay close attention to those with a history of instrumental suicide-related behavior since these patients may underestimate the lethality of the method relative to future suicide attempts (or behavior).

 

Impulsivity and Self-control

 

This area should assess the patient’s perceived sense of self-control, objective identifiers of self-control, engagement in impulsive or self-destructive behaviors and methods for coping with stress (See Table 15 for examples).

 

 

Table 15. Assessment of Self-Control

 

 

Perceived sense of control 

 

Do you consider yourself impulsive?

Why, why not?

Have you recently felt out of control?

 

 

Objective identifiers   

 

How often do you drink or use substances?

Have you had problems with any type of impulsive behavior?

Have you ever been arrested?

 

 

Impulsive/Self-Destructive

Behaviors   

             

 

 

violent, aggressive, sexual acting out

 

 

Coping methods

 

substance use, social withdrawal

 

 

The use of alcohol and other impulse control lowering substances has consistently been found to be associated with increased suicide risk.  Also, the presence of impulsivity as a long-standing problem or personality trait may be a more significant risk factor than a formulated plan.  This is due to the fact that suicide attempts are often in reaction to specific environmental stressors (often unpredictable).

 

Protective Factors

 

There are many factors that have been identified as associated with reduced risk for suicidal behavior and these have been termed protective factors. These are presented in Table 16.  Although risk factors have a stronger relationship with suicidality than protective factors, the latter are important relative to treatment interventions.  Protective factors are important to assess not only related to an overall suicide risk assessment, but also as a starting place for developing a suicide management treatment plan.  Often, the treatment plan for a patient with suicidality will include enhancing protective factors while decreasing risk factors.

 

 

Table 16. Protective Factor in Suicide Risk Assessment

 

 

Social support: strong connections to family and community

Skills in problem solving, coping and conflict resolution

Sense of belonging, sense of identity, and good self-esteem

Cultural, spiritual and religious connections and beliefs

Hopefulness; Identification of future goals

Constructive use of leisure time (enjoyable activities)

Active participation in treatments (medical and mental health, etc.)

Children present in the home

Pregnancy

Life satisfaction

Intact reality testing

Fear of social disapproval

Fear of suicide or death

Absence of potentiating risk factors and warning signs

 

 

Actuarial Risk Assessment Instruments

 

Although most would agree that the core of the suicide risk assessment is the clinical interview, there are a number of suicide risk assessment questionnaires that have been empirically developed and measure various aspects of suicidality. They are most commonly used to augment the clinical interview. 

 

It is beyond the scope of this course to review all of these measures, but some of the more popular ones in use can be found in the Suicide Risk Assessment Guide (Guide HCO; click here for pdf).  As can be seen, the Table provides the name of the scale, author, information about obtaining a copy of the test, copyright information and fees.  In addition, a summary Table (click here for pdf) shows summary information about each scale such as number of items, cost, population use, etc.  This information can help the clinician decide which type of actuarial assessment might be most appropriate given the particular clinical situation. These instruments should never be used as a stand-alone assessment for suicide risk.  These instruments all have a slightly different focus, and the choice of a test will depend on the unique situation of its use (e.g. inpatient/outpatient, age group, treatment setting, etc.)

 

As discussed by a number of authors (see resources and references), the use of these instruments is probably limited in clinical settings.  There is no consensus on which tool is the most effective.  In addition, none of the scales can predict actual suicide attempts.  Several problems have to be kept in mind as can be seen in Table 17.

 

 

Table 17. Problems with Actuarial Suicide Risk Assessment Tools

 

 

High false-positive rate.  The self-report measures show a notoriously high false-positive rate (identifying individuals as high-risk who are not actually at high risk).  This is likely due to the fact that they have been developed based on large populations (or groups) in which a very small target group is being identified.  This is fine for statistical purposes, but becomes a big problem when applied to the individual.

 

Use of stable variables. These instruments often assess historical variables that are static and do not change with time.  As such, they may underestimate the risk contribution of an acute exacerbation.

 

Predictive validity.  The predictive validity of most of these questionnaires has not been established and is probably low.  Research suggests that the ability to predict suicide based on the summary score (or scores) on these risk assessments is low. 

 

Lack of generalizability.  Information is essentially unknown relative to the generalizability of these instruments.  Many of them have been developed for research purposes or for brief screening tools.  Their validity, when using them across different settings (inpatient/outpatient; long term care, emergency room) and groups (adolescent, geriatric, military, race, gender, psychiatric status) is unknown. 

 

 

Probably the most valuable aspect of most of the actuarial suicide risk assessment tools is the collection of additional, pertinent information that can assist in clinical decision making.  In fact, most experts state that the summary scores obtained on these scales are NOT commonly used in practice to make firm decisions about a person’s risk for suicide.  Rather, the actual content covered in the specific items of the tool themselves is more important than the summary scores or cut-off rules. Given these findings, adding an actuarial tool may enhance and specify the information gained from the clinical interview rather than providing specific decision-making conclusion based on summary scores or cut-offs.

 

What do I do with all this Information?

 

We have now covered the type of information that should be gathered as part of a suicide risk assessment, conceptual issues related to suicide behavior, and actuarial tools that can enhance the process.  The obvious question is, How does the clinician quantify this information and how does it guide decision making?

 

Bryan and Rudd (2006) distinguish baseline risk and acute risk. At baseline risk, the individual is not in a state of acute risk and is asymptomatic relative to imminent suicide risk.  Even though potentiating (or static) risk factors may be present, the patient is at his or her best.  The baseline level is unique to each patient.  In some patients, the baseline may represent a state of chronic high risk.  These patients show a history of multiple attempts along with more potentiating factors.

 

Acute risk (or exacerbation) occurs when other factors trigger a number of risk factors (warning signs) and the patient is at his or her worst.  Acute risk can occur on top of any baseline, including chronic high risk.  Hence, Bryan and Rudd 2006) establish four categories of suicide risk:

 

  • Baseline
  • Acute
  • Chronic high risk
  • Chronic high risk with acute exacerbation

 

There is an important reason for these distinctions.  One cannot think of an individual as either “suicidal” or “not suicidal” when assessing and managing these patients.  In contrast, (1) identifiable risk periods occur inconsistently and (2) chronic suicidality complicates any assessment.

 

Taking into account the above conceptualization, suicidality occurs on a continuum. Acute risk increases from non-existent, to mild, to moderate, to severe, and to extreme as intent emerges and becomes clearer in terms of both objective and subjective indicators.  In addition, protective factors will either be minimal (long term) or fade if they had been present.   

 

These concepts have been presented nicely in the Guide and can be seen in the following illustration (Perlman et al., 2011).

 warning_suicide_600

Figure: Accumulation of Potentiating and Warning Factors

 

The following is adapted from Bryan and Rudd (2006, p. 198).  As illustrated in Table 18, the response by the clinician is directly correlated to the intensity of the risk factors.  In the case of severe or extreme suicide risk, immediate evaluation for inpatient hospitalization is indicated (either voluntary or involuntary).  As discussed by Bryan and Rudd, outpatient management of those at moderate and even severe risk can be accomplished taking into account the recommendations briefly summarized in the Table 18.

 

 

Table 18. Suicide Risk Level and Appropriate Responses

 

 

Risk Level

 

 

Description

 

 

Indicated Response

 

 

Nonexistent

 

 

No identifiable suicide intent or suicidal ideation (SI)

 

 

No change in ongoing treatment

 

 

Mild

 

 

SI of limited frequency, duration, intensity; no plan or intent; mild dysphoria; good control; few risk factors; identified protective factors

 

 

Evaluate SI to monitor risk change

 

 

Moderate

 

 

 

Frequent SI, limited intensity/duration, some specific plans, no intent, good control, limited depression, some risk factors, protective factors present.

 

 

 

Recurrent evaluation of need for hospitalization

 

Increase frequency of visits with frequent reevaluation of treatment plan/goals

 

24-hour availability for emergencies or crisis

 

Consider medication if symptoms worsen or persist

 

Use of telephone contact for monitoring

 

Active involvement of family along with their frequent input about indicators

 

Professional consultation as necessary

 

 

 

Severe

 

 

 

Frequent, intense, enduring SI, specific  plans, no subjective intent but objective markers, access to method; limited preparation; impaired control; severe depression;  multiple risk factors; few protective factors .

 

 

 

 

 

 

 

 

 

 

Immediate evaluation for inpatient hospitalization (voluntary or involuntary depending on situation)

 

Extreme

 

 

Frequent, intense, enduring SI; specific  plans; clear subjective and objective intent;  impaired control; severe depression;  many risk factors; no protective factors .

 

 

A COMMENT ON NO-SUICIDE CONTRACTS

 

Many clinicians were trained to use no-suicide or no-harm contracts as part of their education, and the practice is quite common in clinical settings.  A typical no-suicide contract (NSC) contains the following (see Rudd, Mandrusiak & Joiner, 2006):

 

An explicit statement agreeing not to harm or kill oneself

Specific details about the duration of the agreement

A contingency plan if a crisis that would jeopardize the patient’s ability to honor the agreement

The specific responsibilities of both the patient and clinician

 

Unfortunately, several problems have emerged since their inception in approximately 1973.  One of the biggest problems is that there is no solid scientific evidence that they work.  Although many studies have been done using NSC (see Rudd et al., 2006 for a review), they have primarily looked at the prevalence of use.  Those studies that have attempted to look at utility and effectiveness suffer from serious methodological flaws.  Some of the problems with NSC can be summarized as in Table 19.

 

 

Table 19. Problems with No-Suicide Contracts

 

 

The term “contract” contains a “hidden message” that implies more concern for the medial-legal aspects of the issue rather than the clinical process

 

No scientific proof of effectiveness in preventing suicidal behavior

 

Potentially destructive to the therapeutic relationship

 

May lead to a patient’s concealment of suicidal ideation and behavior

 

May lead to a false sense of security in the clinician

 

Useless as a defense in liability litigation

 

 

The information in Table 20 reviews the current use of no suicide contracts (NSC) and suggests there may be problems with this approach especially in terms of their effectiveness (based on Kroll, 2000; Page and King, 2008). As can be seen, even with NSC in place, a very high percentage of patients “under contract” ultimately commit suicide.

 

 

Table 20. Current Use of No-Suicide Contract and Problems

 

 

Percentage of outpatient therapists using no-suicide contracts 

 

 

83%

 

 

Percentage of therapists with no training in no-suicide contracts 

 

 

43%

 

Psychiatrists who make use of no-suicide contracts  

 

 

57%

 

Percentage of therapists reporting a suicide attempt or death by patients while on a no-suicide contract 

 

 

31%

 

Psychiatrists reporting patients who have attempted or completed suicide after agreeing to a no-suicide contract  

 

 

41%

 

 

Alternatives to the No-Suicide Contract

 

Various authors (see Rudd et al., 2006) have recommended alternatives to the NSC.  The focus of these alternative approaches is on using an agreement (not a “contract”) as a clinical intervention.  One such example is the Commitment to Treatment Statement (CTS).  The CTS is defined as an agreement between the clinician and patient in which the patient makes a commitment to the treatment process and to living by:

 

Identifying the roles, obligations, and expectation of both parties

Communicating openly and honestly about all aspects of treatment

Accessing identified emergency services during periods of crisis

 

The focus of the CTS is a commitment to living by engaging in treatment and accessing emergency care, rather than removing the suicide option. The authors recommend that the CTS always be handwritten and individualized to the patient (rather than a standardized preprinted form). The agreement might also include a timeframe depending upon the patient’s input.  A sample CTS can be found in Table 21 (from Rudd et al., 2006 p. 247).

 

 

Table 21. Example of Commitment to Treatment Statement (CTS)

 

 

I, _______ agree to make a commitment to the treatment process.  I understand this means that I have agreed to be actively involved in all aspects of treatment including:

 

  1. attending sessions (or letting the therapist know when I can’t make it)
  2. setting goals
  3. voicing my opinions, thoughts, and feelings, honestly and openly with my therapist (whether they are negative or positive, but most importantly my negative feelings)
  4. being actively involved during sessions
  5. completing homework assignments
  6. experimenting with new behaviors and new ways of doing things
  7. and implementing my crisis response plan when needed (attached)

 

I also understand and acknowledge that, to a large degree, a successful treatment outcome depends on the amount of energy and effort I make. If I feel treatment is not working, I agree to discuss it with my therapist and attempt to come to a common understanding as to what the problems are and identify potential solutions.  In short, I agree to make a commitment to living.  This agreement will apply for the next three months, at which time it will be reviewed and modified.

 

Signed:__________________

Date:__________

Witness:_________________

 

 

This type of agreement has a very different “feel” than a no-suicide contract.  This “agreement” is focused on the patient and on clinical issues related to treatment.  The CTS provides a line for a “witness” signature and this is often a family member.  This underscores the importance of involving family members in this process whenever possible.  The authors suggest that a copy the CTS be kept in the chart and one given to the patient.  It can be updated and modified as necessary. 

 

The authors also recommend the use of a crisis response plan (CRP) which provides specific instructions for the patient during a state of crisis (See Table 22). They suggest writing the instructions on a 3 X 5 card so that the patient can carry it.  As an overview, the first part of the CRP involves self-management skills to enhance crisis management and the final steps include external resources.  The therapist should be very specific about what defines a crisis, especially for those who have been chronically suicidal.  The CRP can be modified as treatment progresses.

 

 

Table 22. Crisis Response Plan (CRP)

 

 

When I am acting on my suicidal thoughts by trying to find a gun (or other method to kill myself), I agree to take the following steps:

 

  1. I will try to identify specifically what is upsetting me
  2. Write out and review more reasonable responses to my suicidal thoughts, including thoughts about myself and the future
  3. Review all the conclusions I’ve come to about these thoughts in the past in my treatment log.  For example, that the sexual abuse was not my fault and I don’t have to feel ashamed of it
  4. Try and do the thing that help me feel better for at least 30 minutes including ______
  5. Repeat all of the above one more time
  6. If the thoughts continue, get specific, and I find myself preparing to do something, I’ll call the person at ________ (phone number)
  7. If I still feel suicidal and don’t feel like I can control my behavior, I’ll go to the emergency room located at ______, phone number ______

 

 

Learning from our mistakes

 

It is beyond the scope of this course to review all of the clinical methods related to the clinical management of suicidality within the context of treatment.  In fact, beyond assessing and monitoring risk as discussed previously, the treatment intervention can take many forms depending on the therapist’s orientation.  An important question, regardless of treatment orientation is,

 

“What mistakes do therapists make that directly relate to preventing a patient from committing suicide?”

 

In an informative study, Hendin et al. (2006) examined 36 cases of patients who died by suicide while receiving open-ended psychotherapy and medication.  In the study, the therapists of the 36 patients completed a number of questionnaires and wrote detailed narratives about each case.  The therapists then participated in an all-day workshop during which critical problems were identified.  According to the authors, six recurrent problem areas were identified and these are as follows. Each of the problems identified is discussed given the information presented in this course.

 

Lack of Communication between Therapists

 

In nine of the cases a lack of communication between therapists created serious problems.  Twenty-three of the patients had been involved in treatment with another therapist before beginning treatment with the therapist during which they died.  In all of these cases, communication between current and previous therapists was rare.  In three cases, after the patient’s death, a former therapist shared information that might have resolved an impasse in treatment.  In two other cases, the patient was hospitalized just before the suicide.  The lack of communication between the hospital staff and the outpatient therapist resulted in misjudgments about the patient’s suicide risk. 

 

As discussed by the authors, the lack of communication was most striking in four cases.  In these cases, a psychotherapist (social worker or psychologist) was providing treatment concomitantly with a psychiatrist (a very common occurrence).  In one case of a patient being treated concomitantly at the same institution, the psychiatrist and social worker had electronic access to each other’s treatment notes, but did not communicate directly.  The social worker was aware that the patient was not taking his medication and that family problems were worsening.  The patient was encouraged to take his medication and agreed he would not commit suicide while his parents were alive (“he couldn’t do that to them”).  In his last session with the psychiatrist nine days before the patient’s death, he admitted fantasizing about shooting himself.  The psychiatrist considered hospitalizing the patient but accepted his promise that he would not kill himself.

 

The day before the suicide, the patient met with the social worker.  He was distressed about family issues, but continued to state he would not kill himself “while his parents were alive”.  The social worker offered more frequent sessions and telephone support.  The patient killed himself the next day.  During all of this time, the psychiatrist and social worker did not speak directly.

 

Case discussion.  In these cases, it is simply unknown as to how the outcome might have been different if the various providers had engaged in direct communication.  Certainly the potential to prevent a suicide might have been enhanced. Direct discussion with past and current treaters is important to complete all elements of suicide risk assessment and management.  It is also good clinical practice.  Not communicating with others involved in the patient’s care (past and present), could be negligent under many of the “Failure to….” categories discussed previously.

 

Permitting the Patient or Their Relatives to Control Therapy

 

In 17 cases, therapists allowed the patient or the patient’s relatives to control the therapy.  On occasion, suicidal patients will attempt to control the course of therapy using the threat of suicide to do so.  In the study, the authors found that in 3 cases, the patient set certain criteria for living and insisted on the therapist’s support in meeting those conditions. In each of those instances, the therapist complied, believing that doing so was necessary to keep the patient alive and in treatment. 

 

In one case, a man with bipolar disorder agreed not to kill himself if he was successful in opening a business in the next 6 months.  His condition for continuing treatment (and living) was that the therapist help him convince his parents to provide financial support for the business.  The therapist agreed and several treatment sessions included the parents. Although the parents agreed, several problems occurred and the business did not open on schedule.  The patient became very agitated and distressed, and the therapist suggested hospitalization.  The patient declined but “agreed to think about it”.  The therapist did not take any further action.  The patient hanged himself that night.

 

In two cases, the patients subtly exerted control by continually alluding to various topics during the course of therapy and then refused to discuss them.  Since the patients were potentially suicidal, the therapists accepted this behavior to avoid upsetting them.  In 9 cases, the patients determined whether and in what amounts they would take their medication.  The lack of adequate medication treatment seriously compromised the therapy, but the therapists continued, feeling they had no choice. In 3 inpatient cases, relatives were allowed to control critical aspects of the treatment that likely compromised suicide assessment and management.  In one case, a patient was given a day pass after the therapist was pressured by a family member.  The patient killed himself while out on pass.  In two cases, after pressure from family members, the patients’ discharged planning was accelerated against the therapists’ better judgment.  Both patients killed themselves in the hospital just before discharge.

 

Case discussion.  In these cases, the patients and family members were allowed to control critical aspects of the suicide risk assessment, management, and overall treatment.  Even with the best understanding of suicide risk assessment and management, unless adequate implementation is completed, the data is worthless.  When patients and family members attempt to control treatment in a deleterious fashion, it most often represents acting out of the pathology in question.  The therapist in these situations (especially the patient wants to control treatment “or else…..”) should definitely seek outside consultation, keep one’s focus on the established assessment and treatment methods, and decide when the patient is simply not willing to commit to treatment (see the course on Difficult Therapy Termination Issues related to patient’s responsibility in treatment).

 

Therapist Avoidance of Issues Related to Sexuality

 

In 7 of the cases, issues related to sexual conflict were clearly avoided by the therapists.  The issues largely involved patients’ ambivalence and conflicts about homosexuality.  In most of the cases, the therapists were aware of the issues, but they were rarely specifically brought up and addressed in the therapy. In one case, a never-married man in his late 30’s with major depressive disorder, suicidal ideation, avoidant personality disorder, and substance abuse was receiving therapy for long-standing conflict about homosexual behavior (he was raised by repressive, Catholic parents).  The patient had several homosexual encounters in his 20’s but was currently searching personal ads for a girlfriend, which was not successful.  He discussed in therapy that a co-worker often teased and humiliated him which was “enraging.”  The therapist believed the co-worker was implying the patient was homosexual, but the patient refused to discuss it in therapy and the therapist did not pursue it.  During what was ultimately to be his last session, the patient came in angry and refused to sit down.  Standing at the door, the patient announced that he was “fed up” and “finished” with work and therapy and was “getting out now.”  The therapist urged the patient to discuss what had happened but the patient refused, left the session, and stated that he would see her next week.  He killed himself the next day.

 

Case discussion.  The case discussed in detail represents one of what appears to be a chronic baseline risk due to the number of potentiating risk factors (see Tables 12 and 18).  In treating a patient with these baseline potentiating factors (static), one must always be aware of a rapid emergence of warning signs or entering an acute exacerbation state.  In this case we do not know if the patient ever overtly expressed suicidal ideation (possible “hidden ideator”), however there were many other identifiable risk factors.  We also do not know if these were specifically assessed or monitored by the therapist.  The patient’s behavior at the last session, especially given all of the potentiating factors, would represent a rapid emergence of multiple warning signs.     

 

Ineffective or Coercive Actions Resulting from the Therapist’s Anxiety

 

In 11 of the cases, the therapist’s anxiety over the possibility of suicide interfered with their ability to treat their patients effectively.  In three of the cases, the patients made their intent to commit suicide clear, but the therapists felt unable to intervene or seek consultation.  In 5 cases, the patients expressed suicidal intent and the therapists suggested hospitalization but left the decision to the patient.  In each case, the patient rejected the suggestion and committed suicide shortly thereafter. 

 

In three other cases, the therapists’ anxiety led to actions that were harmful to treatment.  In one example, presented in the article, a man had been hospitalized for over a year for major depressive disorder and avoidant personality disorder without improvement.  He demanded ECT treatment and attempted to electrocute himself on more than one occasion. In response, a frustrated treatment team had him sign a contract to stop the behavior and threatened early discharge.  The patient overtly complied.  To reward his compliance he was allowed to go on a staff-supervised outing from which he escaped and killed himself.  After the patient’s death, a note in the chart revealed that the patient had told a staff member that his compliant behavior had been an act.  The contract and threat of early discharge caused the patient to suppress his frustration over his lack of treatment and set up a power struggle which the patient “won” by committing suicide.

 

Case discussion.  In the first cases discussed in this section, the therapists apparently did not take appropriate action even when it was clearly indicated.  When suicidality reaches the severe to extreme level (see Table 18), immediate evaluation for inpatient hospitalization is indicated (either voluntary or involuntary).  In these cases, the decision is not left to the patient. 

 

In the case discussed in detail, some of the problems related to no-suicide contracts are portrayed (as discussed previously).  In this case, the contract seemed to act as a blockade to the patient being able to discuss his frustration over his lack of progress in treatment.  One wonders how this case might have been turned out if a therapeutic risk management approach had been taken along with a commitment to living (treatment) agreement rather than a “contract” and threat of early discharge.  This last case also underscores the previous discussion about lack of communication.  Even though, charted (as discovered after the patient’s death), one wonders how the case might have been managed if the staff knew the patient was simply complying overtly.  

 

Not Recognizing the Meanings of Patients’ Communications

 

In 9 of the cases, the meanings of the patients’ communications were not recognized by the therapists.  In one case that exemplifies the problem, a therapist was working with a middle-aged man with a history of bipolar disorder and suicidal ideation who became intensely anxious and unable to function socially or at work.  The patient called his therapist to tell her that he had accidently taken a double dose of his medication.  He asked her if she thought he had made an inadvertent suicide attempt.  She assured him that he had not.  He killed himself later that week.  In retrospect, the patient’s question was communicating an increased preoccupation with suicide that was left unaddressed.

 

Case discussion.  The case presented in detail again underscores the importance of assessing potentiating risk factors that establish a suicide risk baseline.  Against this “baseline” all future “warning signs” or acute exacerbations can be judged.  As discussed in this course, patients will not always present a clean set of data indicating that an acute phase is being entered.  However, any small warning sign can signal the therapist to immediately and directly assess other risk factors.  In this case, if the therapist had accepted the patient’s conclusion that it might have been an “inadvertent” suicide attempt, more aggressive assessment of warning signs might have been completed along with appropriate intervention.    

 

Untreated or Undertreated Symptoms

 

In 17 cases, the patient exhibited major symptoms related to substance abuse, anxiety, and/or psychosis, but these problems were not adequately addressed in treatment.  As the authors point out, the most striking example was 11 patients who had active substance abuse problems which were not treated.  In 15 cases, the patient’s intense anxiety in the period preceding the suicide was not adequately treated.  In 3 other cases, the patients presented with clear psychotic symptoms that were either undiagnosed or untreated.  

 

Case discussion.  In all of these cases, one wonders what the outcome might have been if a suicide risk assessment had been completed along with appropriate monitoring.  The presence of substance abuse (active) is always a concern given the lowered impulse control.  It also appears that the emergence of “intense anxiety” may not have been adequately assessed and treated as it was a prodrome to acute exacerbation of suicidality. 

 

 

These cases exemplify what can happen if suicidality is not assessed and managed properly.  As Hendin et al. (2006, p. 70) point out,

 

“Therapists’ fear that a patient may commit suicide frequently impeded their ability to deal effectively with the danger.  Paradoxically, we have found that therapists who recognized that a patient was in suicide crisis are often shocked when the patient actually kills himself or herself suggesting that some therapists deal with that anxiety by denying that what seems possible, or even likely, could actually happen.”    

 

Documentation

 

The level of suicide risk should be clearly documented along with information to support this assertion. There is no “gold-standard” in terms of this type of documentation; however, the suicide risk assessment should address important variables as outlined in Table 12 and the protective factors as outlined in Table 16, along with the clinician’s reasoning supporting treatment decision-making (Table 18).  Any methods used to complete this assessment should be documented such as clinical interview, suicide risk questionnaires, interviews with family members, discussions with other treaters, etc.  The documentation should also include a discussion of baseline suicide risk factors (or “predisposing” or static variables) along with acute symptoms (warning signs) that may or may not be present.  It is also important to document protective factors since these will tend to attenuate the suicide risk and are often the focus of ongoing treatment. 

 

The following case examples demonstrate documentation for suicidality in mild risk and severe risk cases.  The format has been adapted from Bryan and Rudd (2006).

 

Case example of mild risk. This is a 55 year old male construction worker who was injured on the job approximately 10 years ago.  He had always been a hard worker, being in the field for over 25 years prior to his injury.  He continued to work after the injury until a spine surgery.  He has been totally disabled for the past 8 years due to back pain.  He is married with two children.  His wife has had to return to work to help support the family.  The patient lost his home due to financial problems.  He has been battling various agencies to get approved for disability support.  His previous suicide behavior (5 years ago) occurred in response to being turned down for various treatments and disability support.  He had no psychiatric history prior to the injury but has been in treatment for depression since then.

 

 

Table 23. Example of Documentation – Mild Risk

 

 

Risk Category:  Some Chronic Risk Factors with Mild Risk Level

 

Acute Risk Indicators:

 

SI is frequent but limited intensity/duration

SI in response to identifiable situational stressors

(turned down for disability for second time; plans on appealing)

Some ideas about a plan but nothing specific

No intent; No availability of lethal means (gun, prescription meds)

Good current self-control

Alcohol use 1 time per week, 1-2 ounces

Mild, transient dysphoria

 

Predisposing/Chronic/Static:

 

Previous outpatient treatment for depression with medication

History of instrumental suicide-related behavior

(two occasions over 5 years ago; alleged overdose of OTC medications in front of significant others; taken to ER and released on both occasions; no involuntary hold)

Chronic pain and disability after a work injury 10 years ago

Ongoing financial distress

Loss of work identity and ability to support family

 

Protective Factors:

 

Strong social support (family, church group)

Patient actively involved in treatment

No history of substance use

Beginning to become involved in volunteer activities

 

Severity Rating: (0-10) = 5

 

Treatment Plan:

 

Patient agreed to, and signed, a Commitment to Treatment Statement

Patient agreed to Crisis Response Plan

Cognitive Behavioral Therapy initiated focusing on enhancing protective factors.  Treatment will also include involvement of family members.

 

 

Case example of severe risk. The patient in Table 24 is adapted from Bryan and Rudd (2006).  This is a 46 year-old twice divorced female who is in her third marriage which she describes as “happy” (or “…at least better than the first two”).  She currently works part-time and cares for her two teenage children (one from each previous marriage). She has a long history of an eating disorder (currently active) and a history of being sexually abused as a child by an uncle.  She has a history of suicide attempts (three occasions before 25 years old by overdose) but she never told anyone. She constantly “worries” and feels guilty about the eating disorder and abuse history. Stress includes work and family.  She feels “worthless” and like she will “never live up to her potential.”  She drinks alcohol and smokes marijuana to help with her stress.  Her social support is minimal outside of her immediate family.  She has a very strained relationship with her family of origin and little contact with them.  She revealed that her husband keeps a gun in the house “for protection.” When asked about a plan, she was vague but stated that, “if things become too bad, I could just shoot myself.” The patient has never had contact with a mental health professional.       

 

 

Table 24. Example of Documentation – Severe Risk

 

 

Risk Category:  Chronic High Risk Factors with Acute Exacerbation

 

Acute Risk Indicators:

 

SI is frequent but limited intensity/duration

SI increases in response to identifiable situational stressors

Some ideas about a plan along with some specificity

No expressed intent currently but availability of lethal means (gun)

Diminished self-control with impulse lowering substances

Admits to daily alcohol use (2-3 ounces, reported)

Moderate dysphoria (reported)

Ongoing eating disorder with guilt

 

Predisposing/Chronic/Static:

 

History of three suicide attempts

(three occasions before 25 years old by overdose – never told anyone)

Social support network very limited

Family and work stress (fluctuates but currently acute)

History of abuse

Eating disorder

Personality features

 

Protective Factors:

 

No significant protective factors identified

 

Severity Rating: (0-10) = 10

 

Treatment Plan:

 

Given the alcohol use and the availability of a gun, this represents an emergent situation.  Even though the patient acknowledge she was not currently feeling like she would act on the SI (explicit or subjective intent low), the implicit or objective intent is significant.  The gun issue must be addressed immediately in terms of getting it out of the house.  This might be done by contacting her husband and insuring this is done (immediately).  Just having the patient “promise” to ask her husband to remove would not be adequate.

 

Before leaving the initial session, (after her husband was contacted about removing the gun and informed of the situation), the patient agreed to, and signed, a Commitment to Treatment Statement.  Also, a Crisis Response Plan was developed.  The patient’s husband was supportive of the treatment.

 

After the home environment is made safer, she may be managed on an outpatient basis with frequent contact (“least restrictive”) depending on other issues and the course of treatment.  Hospitalization should always be an option.

 

As part of the outpatient treatment, she might be referred for medication consultation (for dysphoria and agitation), substance detoxification, and involvement of her husband in the treatment.  Mobilization of any social support systems would be critical. 

 

 

Summary and Conclusions

 

The following Table summarizes some of the important issues in suicide risk assessment and management.  Using a therapeutic risk management approach, suicidal risk assessment and management is integrated into good clinical care.

 

 

Table 25.  Summary of Suicide Risk Assessment and Management

 

 

Document, Document, Document.  There is a saying in legal circles that, “If it isn’t written down, it didn’t happen”. Be sure and document interactions, consultations, professional judgments and the “why’s and why not’s” in treatment decision-making.

 

Consult and Communicate.  If necessary, one should consult with colleagues who have experience with suicidal patients. Be sure and communicate with any practitioners who have treated the patient in the past or are doing so concurrently. 

 

Know Legal and Ethical Responsibilities.  Being familiar with legal and ethical responsibilities helps the clinician recognize risk before it becomes liability.  We also recommend using the concept of “therapeutic risk management” so that risk management is done within a therapeutic context.  

 

Know the Risk Factors of Suicidal Patients.  Clinicians must know what the literature says about suicidal risk factors to exercise sound clinical judgment.  These include such things as potentiating risk factors, warning signs, acute signs, explicit and implicit intent, chronic baseline levels of risk, protective factors, etc.

 

Obtain Risk Assessment Data and Adequate History.  A thorough clinical assessment of elevated suicidal risk must be completed consistent with evidence based research and the standard of care.  Guidelines such as those reviewed in this course and found in the resources should be followed.  Suicide risk should be re-assessed on a regular basis.

 

Determine Diagnostic Impression.  Be sure and provide an accurate diagnosis consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).  Resist the temptation to “underdiagnose” as this is legally risky and not an advisable risk management procedure.

 

Determine Your Competence.  Be aware of your own proficiency in working with a suicidal patient.  Take whatever steps are necessary to ensure adequate evaluation, treatment and follow through with the patient (e.g. consult, on-going education, refer).

 

Involve the Family.  It is often important to involve the patient’s family in the evaluation and treatment process.  If appropriate, family involvement can increase the effectiveness of the intervention and protect the clinician from litigation.

 

Don’t Let Patients Control Your Better Judgment.  As was seen in the study looking at likely therapists mistakes in suicide risk and management, allowing patients and relative to control the treatment was not uncommon.  It is important follow through appropriately regardless of attempted coercion by others.

 

 

If a practitioner determines a patient to be suicidal, precautionary measures such as involuntary or voluntary commitment for observation may have to be invoked; although, in some cases, using sound clinical judgment, the suicidal patient may be most appropriately managed on an outpatient basis. As long as the standard of care is commensurate with community standards and the treatment decision is in the best interests of the patient, there would be no grounds for negligence if the patient is treated in the “least restrictive” environment and appropriate suicide risk management is ongoing. 

 

Resources

 

Suicide Risk Assessment Guide Ontario Hospital Association. (2011; 122 pages)

 

American Psychiatric Association (2003). Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors  (123 pages).

 

Stop a Suicide (stopasuicide.org)

 

American Association of Suicidology (suicide.org).

 

SUGGESTED READING

 

Bernstein, B. E. & Hartsell, T. L.  (2004). The portable lawyer for mental health professionals, 2nd ed.  Hoboken, New Jersey: John Wiley & Sons. 

 

Campbell, T. & Lorandos, D.  (2001). Cross examining experts in the behavioral science.  Danvers, MA: West Group. 

 

Lifson, L.E. and Simon, R.I. (1998).  The mental health practitioner and the law: A comprehensive handbook.  Cambridge, MA: Harvard University Press.

 

Reamer, F.G.  (2003).  Social work malpractice and liability, 2nd ed.  New York: Columbia University Press.

 

Shapiro, D.L. and Smith, S.R. (2011).  Malpractice in liability: A practical resource for clinicians.  Washington, D.C.: APA Books.  

 

REFERENCES

 

American Psychiatric Association (2003). Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. Washington, D.C.  (123 pages).

 

Antony, M. M., & Barlow, D. H. (Eds.). (2002). Handbook of assessment and treatment planning for psychological disorders.  New York: The Guilford Press.

 

Bryan, C.J. and Rudd, M.D. (2006).  Advances in the assessment of suicide risk.  Journal of Clinical Psychology: In Session, 62, 185-200.

 

Bernstein, B. E., & Hartsell, T. L. (2004).  The portable lawyer for mental health professionals, 2nd ed.  Hoboken, New Jersey: John Wiley & Sons.

 

Campbell, T., & Lorandos, D.  (2001). Cross examining experts in the behavioral science.  Danvers, MA: West Group.

 

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: controversies and evidence.  Annual Review of Psychology, 52, 685-716.

 

Charles, et al. (1985). Sued and nonsued physicians’ self-reported reactions to malpractice litigation. American Journal of Psychiatry, 142, 437-440.

 

Hammer v. Rosen, 7 N.Y.2d 376, 165 N.E.2d 756, 198 N.Y.S.2d (1960).

 

Hendin, et al. (2006). Problems in Psychotherapy with Suicidal Patients. American Journal of Psychiatry, 163, 67-72.

 

Kroll, J. (2000). Use of no-suicide contracts by psychiatrists in Minnesota.  American Journal of Psychiatry, 157, 1684-1686.

 

Markus, R. M. (1965). Conspiracy of silence. Cleveland Law Review, 14, 520-533.

 

Moore, P.J., Adler, N.E., & Robertson, P.A.  (2000).  Medical malpractice: The effect of doctor-patient relations on medical patient perceptions and malpractice intentions.  Western Journal of Medicine, 173, 244-250.

 

Nathan, P. E., & Gorman, J. M.  (Eds.). (2002). A guide to treatments that work, 2nd ed.  New York: Oxford University Press.

 

Packman, W., & Smith, G.  (2006a). Suicide and malpractice risk. Part I, legal basics.  The California Psychologist, May/June, p. 23-24.

 

Packman, W., & Smith, G.  (2006b).  Suicide and malpractice risk. Part II, risk management strategies. The California Psychologist, July/August, pp. 29-30.

 

Page, S.A. and King, M.C. (2008). No-suicide agreements: current practices and opinions in a Canadian urban health region. Canadian Journal of Psychiatry, 53, 169-176.

 

Perlman et al. (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canandian Health Care Organizations.  Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.

 

Roy v. Hartogs, 85 Misc.2d 891, 381 N.Y.S.2d 587 (1975).

 

Rudd, M.D. (2008). Suicide warning signs in clinical practice.  Current Psychiatry Reports, 10, 87-90.

 

Rudd, et al. (2006).  Warning signs for suicide: Theory, research, and clinical applications.  Suicide and Life Threatening Behavior, 36, 255-262.

 

Shea, C.S. (1998).  Psychiatric Interviewing: The Art of Understanding.  Philadelphia, PA: W.B. Saunders.

 

Simon, R.I. (1998). The suicide patient.  In LE Lifson and RI Simon (Eds), The mental health practitioner and the law: A comprehensive handbook (pp. 166-186.  Cambridge, MA: Harvard University Press.

 

Simon, R.I. (2006).  Suicide risk assessment: Is clinical experience enough?  The Journal of the American Academy of Psychiatry and the Law, 34, 276-278.

 

Simon, R.I. and Shuman, D.W. (2009). Therapeutic risk management of clinical-legal dilemmas: Should it be a core competency? The Journal of the American Academy of Psychiatry and the Law, 37, 155-161.

 

Smith, A.R. et al. (2008).  Revisiting impulsivity in suicide: Implications for civil liability of third parties.  Behavioral Sciences and the Law, 26, 779-797.

 

Thyer, B.A., & Wodarski, J.S.  (2007).  Social work in mental health: An evidence based approach.  New York: Wiley.

 

Tsao, C.I. & Layde, J.B. (2007). A basic review of psychiatric medical malpractice law in the United States.  Comprehensive Psychiatry, 48, 309-312.

 

Author Disclaimer

 

The course reviews ways to minimize risk, but it does not provide legal advice; nor should it substitute for the assistance of legal counsel, should a practitioner encounter legal issues in his or her practice.  This course provides an analysis of some legal issues that may arise in the practice of psychotherapy.  This course is not a final decision on any ethical or legal subject, as all ethical and legal issues are constantly under revision and consideration.  This material is not meant as a personal or clinical consultation, nor is it meant as a substitution for contact with an ethics committee, attorney or professional consultant. 

 

 

 

 



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