© Lawrence E. Hedges, Ph.D., Psy.D., ABPP
Considering and predicting suicide risk is one of the most widely researched areas in psychology. While many interesting and objective scales and tests have been devised, unfortunately, massive research continues to demonstrate to date that there are no valid and reliable ways of predicting non-lethal or lethal suicidal behavior.1 But there are many important known risk factors that every clinician must be familiar with and consider in her/his clinical assessment of how to handle the dangers.
Suicide Contracts and Precautions against Self-Abusive Activities
Suicide and self-abuse contracts alone are an insufficient standard of care. Common sense requires that you regularly do risk assessments and take emergency measures if the risk is high. If the risk is moderate, you must mobilize social and family support. If the risk is low, you can continue with careful follow-up. While most attorneys want us to
document all suicidal and self-abusive gestures and risks carefully in our notes, some experts point out that a documented risk assessment immediately before a seriously damaging or successful suicide attempt could put us in potential jeopardy. But we want to err on the side of safety. It is always best to document carefully and to seek immediate peer and specialty consultation to cover yourself. You can more easily be defended for a well-reasoned, good-faith breach of confidentiality in a clearly dangerous circumstance than for suicide, homicide, or for serious self or other injury.
All therapists need ongoing continuing education in the area of suicide risk management since research findings continue to expand this critical area of practice. Make it a point whenever you see a book, and article, a workshop or an on-line course on suicide prevention to take it and to keep documentation of your ongoing training experiences since there is no clearly fixed knowledge base or tried and true guidelines in this area. Another way of documenting your ongoing training in this or any speciality area is to download articles and file them in your Continuing Education folder and/or in a particular client’s record—that way your efforts will be documented and dated.
Suicide Liability Risk Management: A Summary
Psychologist/attorney Bryant L. Welch lists eight areas of ongoing concern.2
- Do an initial comprehensive suicide risk assessment of the patient and make assessment an ongoing part of treatmen Be mindful of the suicide risk factors, tapping the latest available literature on the subject.
- Don’t allow yourself to deny a suicide risk.
- Spend adequate time with the patient—whether you get paid for all of it or not.
- If necessary, make it clear to the managed care company that a lack of treatment could be seen as negligence and result in a lawsuit against them—put this in a certified letter to the managed care representative if necessary.
- Practice full disclosure with the family of the suicidal patien
- Educate the patient’s family about the signs of potential suicide.
- Employ good follow-up practices with patients.
- Always follow good documentation procedures.
Pope and Vasquez list what continues to be critical areas to evaluate in determining the risk of a suicide. 3
- A direct verbal warning is the single most useful predictor.
- The presence of a plan increases the risk.
- Eighty percent of completed suicide attempts have been preceded by previous attempts.
- People give away their plans by indirect references.
- Depression is a significant predictor; 15 percent of clinically depressed people kill themselves.
- Hopelessness is highly associated with suicide inten
- One-fourth to one-third of successful suicides are associated with drug or alcohol intoxication.
- Suicide rates are higher in diagnosable clinical syndromes such as depression, alcoholism, primary mood disorders, and schizophrenia—and with relatives of clients who have committed suicide.
- The suicide rate for men is three times greater than for women, and five times higher for young men.
- Suicide risk increases with age and the life cycle, peaking between the mid-50s to the mid-60s.
- In the United States Caucasians have the highest rate.
- Suicide rates are higher among Protestants than among Jews and Catholics.
- The risk is highest for those living alone, less if living with a spouse, and less if there are children.
- Bereavement over lost loved ones in recent years increases the risk.
- Unemployment increases the suicide risk.
- Illness and somatic complaints, just like sleep and eating disturbances, increase the risk.
- Those with high impulsivity are at increased risk for taking their own lives.
- Rigid thinking increases the risk, for example, a person who says such things as, “If I don’t find work in the next week the only real alternative is to kill myself.”
- Any stressful event is likely to destabilize a person, putting her or him at higher risk for suicide.
- The risk is greater after weekend hospital leaves and after being discharged from a hospita
Clients who engage in chronic and intractable suicidal gestures, self- mutilating activities, or other potentially self-abusive or harmful behaviors may need to be terminated and referred out of individual psychotherapy on the basis of unmanageability. The resources we have at our disposal often do not meet the client’s needs. This must be explained to the client early in therapy, and limits must be set and put into writing with consequences that are effectively followed through on. I have seen many therapists struggle compassionately for long periods of time with clients, making clear in a no- fault, non-punitive fashion that they are not equipped to deal with such intense and dangerous expressions, so that these forms of communication have to be renounced in order for therapy to continue. It is usually the therapist’s resistance to limit-setting and systematic follow-through that slows down the process. But the bottom line is that no therapist is in a personal or professional position to receive endlessly or to respond effectively to chronic life-threatening or safety-endangering communications.
If it is not possible to contain the therapy work in manageable limits, the client must be referred to a more appropriate intensive therapeutic resource or to a setting where different liability parameters exist. Almost all clients confronted in this seemingly harsh way about how important their therapy work is, how crucial safe and manageable nonthreatening communications are for the sanity and well-being of the therapist, and how the client must find alternative forms of experiencing and communicating her or his concerns, in fact, do find different, creative, and contained ways of continuing their therapy work with the therapist safely. But the therapist has to believe that alternate forms of communication are essential for mutual safety and that they are achievable within the creative potential of the client for the limit setting to work effectively. If the client truly cannot comply in this way your liability is simply too great to continue with her or him.
1 While there are many fine books on suicide risk, the book which presents the most comprehensive review of the literature and available research to date is Assessment, Treatment, and Prevention of Suicidal Behavior edited by Robert I. Yufit and David Lester with a forward by foremost suicidologist Norman Farberow (Wiley, 2005).
2 Welch, B. L. (2000). Reducing Your Suicide Liability. Amityville NY: American Professional Agency.
3 Pope, K and Vasquez, J. (1991). Ethics in Psychotherapy and Counseling: A Practical Guide for Psychologists. San Francisco:Jossey‐Bass.