Suicide Risk Assessment: A Practical Approach [Ethics and Risk Management]by William W. Deardorff, Ph.D, ABPP.
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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 Ellis, 2012; Meyers, 2015; Schwartz & Rogers, 2004; Tsao & Layde, 2007 and references for a review):
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. See Ellis, 2012).
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).
Suicide in the United States
The following Figures and summary Table is just a sampling of data from the NIMH and CDC websites related to suicide (updated May, 2018 with 2016 data). This is general data and more detailed information can be found on the NIMH Suicide Statistics 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.).
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. Here are some examples related to the military, certian age groups, gender, ethnicity, etc. But, let's start trends in suicide rate over time from 1999-2016. As can be seen, the rates are increasing:
Figure: Suicide Rates over Time
Here is some information about suicide rates in the military both over time and compared to a civilian population:
Figures: 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, 2016 data from the Centers for Disease Control). Any therapist working with this age group should certainly be aware of this information.
Figure: High school students – Suicidal ideation
This figure is also consistent with more current data relative to age and suicide thought and suicide attempt as follows:
Figure: Age and Suicide Thoughts
Figure: Age and Suicide Attempt
Other areas to be aware include gender and ethnicity (shown above for attempts and in the following):
Figure: Suicide Rates by Gender
Figure: Suicide Rates by Gender and Race
Other important data includes information about suicidal behavior as can be seen in the following:
Figure: Suicidal Behavior
These are just some 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, 2018 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, 2018). 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, 2018). As concluded by Campbell and Lorandos (2018), “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, 2015). 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, 2015). 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):
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):
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, 2015 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.
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).
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).
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).
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, 2010) 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.
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).
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, 2010). 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):
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.
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:
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; Practive Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, 2010, 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):
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).
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).
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.
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). 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.
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:
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). 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.
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.
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.
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).
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.
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.
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.
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.
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.
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 (2010). 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).
Screening for Suicide (ZeroSuicide)
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 (2010). 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.
Ellis, T.E. (2012). Client suicide: What now? Cognitive and Behavioral Practice, 19, 277-287.
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.
Meyers, C. (2015). Facing the specter of client suicide. Counseling Today, October 19, 2015.
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.
Reamer, F.G. (2015). Risk management in social work: Preventing professional malpreacgtice, liability, and disciplinary action. New York: Columbia Univeristy Press.
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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