The Ethics of Working With Suicidal Clients

Paper in blurry focus
“Losing-Focus” by LOLitsLloyd on Flickr creative commons

I wrote this essay years ago, when I was still in grad school and had no idea that I would end up specializing in suicide prevention later in my career! I came across it recently and thought it would be interesting to share it, edited for length including removing all research references (didn’t think a 2700 word academic paper would be too popular. I can post the references if anyone would like to see them). Bit more formal than my usual online writing, but hope you enjoy!

Client suicide can stir anxiety into the hearts of even the most seasoned practitioners: it frequently appears in lists of the situations therapists fear most. In a culture of healing dominated by the medical model, ‘suicide’ and ‘failure’ are functionally interchangeable terms, and the many consequences for those in the helping professions whose clients complete suicide are dramatic – ranging from therapist impairment to vicarious traumatization and, in many cases, malpractice suits. It is no wonder, then, that the ethics of suicide and suicide prevention have been given widespread attention in the literature.

Informed Consent

Informed consent takes on a new level of importance when working with suicidal clients. Research shows that informed consent with a suicidal client can help to provide structure to treatment, disclose risk appropriately, and inform the client of ground rules such as the limits and boundaries of confidentiality – a necessity considering the issues of duty to warn and involuntary hospitalization that go along with suicide risk. Legally, informed consent carries a significant weight – if inappropriate or lacking informed consent is discovered, a counsellor being sued for malpractice following a completed suicide is far more likely to be found liable due to not demonstrating competent care.

Evidence is now surfacing that supports being as open about the process of treatment as possible and empowering client decision-making even, and perhaps especially, in the face of such a powerful issue as suicide. For any major progress to happen in the area of counselling suicidal clients, the spirit underlying informed consent needs to be embraced. It must be understood to be more than a couple of signatures obtained in the first session.

Risk Assessment

Risk assessment is often seen as an attempt to predict whether a suicide attempt will occur. However, the responsible counsellor’s task is not to predict suicide; instead, counsellors must know when clients are in a high-risk state and take the appropriate action to maximize client safety. This also informs the concept of reasonable care, which includes comprehensive and timely treatment based on risk assessment. Without a thorough assessment of suicide risk, counsellors cannot claim to be providing competent care as such an assessment has the potential to inform dramatic changes to the treatment plan of a suicidal client depending on the level of risk.

Accurate suicide risk assessment can be broken down into two main categories: risk factors and warning signs, the latter now seen as carrying much more significance in terms of informative value. While standard risk factors remain important considerations, the importance of knowing warning signs, which indicate a much more immediate risk of suicide, cannot be overstated. Such signs include hopelessness, severe anger, increased substance use, withdrawal, dramatic mood change, and seeing no purpose in life. It is essential to know as much as possible about the client’s intent to attempt suicide and warn that there is often a discrepancy between explicit, directly stated intent and implicit, counsellor-estimated intent. Resolving this discrepancy is essential to making an accurate assessment and consequently, decisions about treatment as a whole.

Treatment Style

How to go about treating suicidal clients should be seen as an element of competent care alongside the content, or what is done. Traditionally, two problematic styles have been dominant in the treatment of suicidal clients: the “fight” and “flight” styles. “Fight” is descriptive of the traditional crisis intervention model, in which the interventionist aggressively and assertively takes control of the discussion and decisions made. This stems from the needs of the counsellor without first taking into account the needs of the client, and can go to the length of using force, fraud, and struggling for power in a situation where the client is desperate for control over their life. In general, the style may be hostile and judgmental in order to achieve such goals as involuntary hospitalization and forced medication.

At the opposite extreme is the “flight” style, characterized mainly by a fear of discussing suicide at all, and an overly passive and disinterested style. A counsellor using this style might ask a leading question such as “you’re not thinking of hurting yourself, are you?” and ignore or downplay hints at suicidality out of concerns for their own interest and the extra time investment involved in a proper assessment. It is obvious that the “flight” style is the most unethical way to respond to a suicidal client – but is there a better option than “fight?”

One solution is an a “ideal” style in which client and therapist maintain a respectful, genuine and collaborative relationship and suicide is discussed non- judgmentally and openly from the client’s point of view. Empathic understanding is sought at all times and actions are only taken against the client’s will when no other options are available.

No-Suicide Contracts vs. Commitment to Treatment Statements

A no-suicide contract is a statement, signed by client and therapist, that a client will not commit suicide during treatment. Despite the term ‘contract,’ these documents are in no way legally binding, and may even be used as evidence of malpractice in a lawsuit brought against a therapist if relied on to the exclusion of a proper suicide-risk assessment. Despite the widespread use of no-suicide contracts, there exists no empirical support for their use. They appear to be more useful as a tool to measure the strength of the therapeutic alliance than in any other application: clients who share a strong relationship with their therapist are likely to see them as a demonstration of genuine caring; those with suspicions may see them as a means to relieve the therapist’s own anxiety about suicide and its ramifications.

An alternative to the no-suicide contract is the commitment to treatment statement (CTS). The CTS is an agreement that the client will commit to therapy and outlines what this will look like, such as identifying the roles of client and therapist, communicating openly and honestly, and accessing emergency services during crises that threaten a client’s ability to honour the agreement. The latter is facilitated by the creation of a crisis response plan (CRP) that details steps the client can take in a crisis situation to ensure their safety, from self-soothing techniques to calling a crisis line or emergency services. Both documents are formulated collaboratively with the client in handwriting during the session, and should be revisited and revised as therapy progresses.

Breaking Confidentiality and the “Duty to Protect”

The Canadian Psychological Association’s Code of Ethics advises psychologists to “do everything reasonably possible to stop or offset the consequences of actions taken by others when these actions are likely to cause physical harm or death.” It is the responsibility of therapists to take appropriate action to prevent suicide, including breaking confidentiality in order to alert family members or authorities of an imminent suicide risk. This understandably puts a lot of pressure on professionals who see suicidal clients. There is potential for liability on either side of this prediction: if confidentiality is broken and it is deemed unwarranted, a counsellor could very well be sued for malpractice; if the counsellor does not break confidentiality and a client attempts or dies by suicide, they could be found liable of malpractice. A higher value must be placed on saving lives than on preventing lawsuits – any risk-benefit analyses behind the decision to break confidentiality must err on the side of client safety.

The Debate on Involuntary Hospitalization

Breaking confidentiality with imminently suicidal clients often leads to voluntary or involuntarily hospitalization so that a more structured and intensive inpatient treatment can be implemented. In keeping with the “ideal” style described earlier, involuntary hospitalization should only be considered when all other options, including voluntary hospitalization, have been exhausted. Committing someone to inpatient treatment against their will is an incredibly aggressive and dehumanizing intervention that is not only damaging to the therapeutic alliance, but also to a client’s sense of autonomy. Additionally, average hospital stays for suicidal clients now range from only three to four days, the intervention itself is becoming less and less economically sustainable, and the medication-centric approach used in most hospitals is coming under heavy scrutiny with the literature currently favouring psychosocial approaches. Nonetheless, involuntary hospitalization is an intervention that has and will continue to save the lives of many suicidal clients, and research on the treatment outcomes of involuntarily and voluntarily admitted clients shows minimal differences between the two groups. In making the decision to commit a client involuntarily, it is best to be clear and decisive, and to remember that forced hospitalization is always a better option than allowing an imminently suicidal client who refuses voluntary hospitalization to return home to contemplate their crisis.

This paper has outlined the importance of competent care of suicidal clients as demonstrated by informed consent, risk assessment, intervention style and the value of specific tools such as the CTS and CRP to raise the argument that the concept of competent care must be grounded in empirically supported procedures and a genuine concern for the welfare of the client via an “ideal” collaborative style that maximizes autonomy and dignity. The complications inherent in ethical decision making when counselling suicidal clients are highlighted using the risks of breaking confidentiality and forcing involuntary hospitalization – I argue for thorough contemplation of the risks and benefits of the above while remaining aware of the need to err on the side of client safety. While the issue of suicide is understandably accompanied by feelings of anxiety and discomfort, there is every reason to believe that promising advances will continue to be made in the field, and hopefully fewer will make the final choice to end their lives.

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