Page 18 - Jan/Feb 2017 FTM

Suicide and Malpractice:
Managing Risk
WHILE LEADING A RECENT TRAINING on family therapy with suicidal adolescents, an audience member asked, “What do you do when your client won’t do the homework you’ve assigned?” I hear questions like this frequently and typically respond directly to the question. Ultimately, I am left rather unsatisfied with the content of the discussion and a feeling that something is left unsaid. This time, utilizing my emotion-focused therapeutic intuition, I pressed pause on our training agenda and took a minute to address the question. Ultimately, the question was not about homework, nor was it about client unresponsiveness. The concern underlying the words was, “I’m scared of being sued.” The real question was, “How do I protect myself from legal action when working with clients at high risk of suicide?” The following will outline a few of the concerns we face when working with suicidal clients and how to protect ourselves.
Ethical concerns and malpractice
The concerns expressed during the aforementioned training are not unfounded. In all honesty, sometimes suicidal clients are some of the most complex and difficult cases. Often, these clients have long histories of treatment, multiple diagnoses, or are noncompliant. However, almost everyone working in mental health will have clients with high levels of depression or suicidal thoughts. Half of psychiatrists and more than one quarter of psychotherapists will have a client die by suicide over the course of 20 years (cf. Jobes & Berman, 1993).
It is commonly believed that a person dying by suicide while in treatment is solid evidence of a therapist’s failure to perform their number one duty—to keep the client alive. Suicide loss survivors report blame, anger, outrage, and contempt toward the therapist who had been working with the deceased (Peterson, Luoma, & Dunne, 2002). More than half of family members bereaved by suicide seriously consider contacting an attorney after the death— one quarter do (Peterson, Luoma, & Dunne, 2002). Should this happen, that means an expert would likely look at the treatment charts to determine if there is a case of malpractice.
It is complicated, but essentially this means that an examination of the treatment would be conducted to determine if there was negligence and if this negligence is the cause of the death. This
is determined either through acts of commission or omission (either doing something that should not have been done or not doing something that should have). There is not an expectation for therapists to be perfect or to predict the future. Essentially, the question of malpractice and the standard of care comes down to, “what is the reasonable and prudent expectation of the average practitioner of similar training and locality (Berman, 2011)?”
Reasonable and prudent clinician behavior includes five things (Berman, 2011). First, a systemic assessment and formulation of suicide-related thoughts and behaviors. Second, the creation of a treatment plan to address and reduce suicide risk. Third, the
reliable implementation of the treatment plan. Fourth, continual evaluation of risk and progress. This includes revisions to the treatment plan when needed. Finally, there is an expectation of continuity of care that includes both reasonable client access to therapist during treatment and resources to help as treatment terminates. There is not an expectation for therapists to be immediately accessible at all times, but Berman (2011) does suggest 24 hours is generally adequate. While each of these five points are important, we will focus primarily on assessing and documenting suicide risk.
Assessing and documenting suicide risk
It is important to specifically identify and document risk factors and how they fit with your client. The American Association of Suicidology (2016) suggests using the pneumonic device I.S. P.A.T.H. W.A.R.M. to remember common risk factors for suicide: Ideation, Substance abuse, Purposelessness, Anxiety, Trapped feeling, Hopelessness, Withdrawal from family and friends,
Anger, Recklessness and impulsivity, and Mood changes. A more comprehensive list of risk factors includes: history of prior suicide attempts, recent divorce/breakup/death, access to firearms and other highly lethal means (medical grade drugs, illegal drugs), religious or cultural beliefs that conflict with sexual orientation or gender identity, recent crises, perfectionism, and low self-worth. While old white men are often cited as most at risk for suicide, it is worth noting that sexual and gender minorities (especially when combined with racial and ethnic minority status) are often at high risk for suicide or suicide-related thoughts and behaviors.
After assessing risk factors and thoughts of desiring to die, it is important to identify protective factors and how they fit with your client. Many people with significant stress and suicide ideation continue to live happy and fulfilling lives because they have something providing a purpose and helping them feel as if they belong. If there are no protective factors noted, it may be hard to justify letting the client out of your session. Many protective factors relate to the systems in which the person lives (relationships, religious/spiritual belief, social support, healthcare) but internal factors, like ability with coping skills and sense of control, are also important.
The last part of suicide assessment is creating a safety plan. Do not use a safety contract or no harm contract. There is some evidence that no harm contracts actually increase liability risk because they acknowledge the person is at risk for suicide without improving treatment (Berman, 2011). The point of the safety
plan is not to mitigate liability, but to improve client care and improving client care will mitigate liability. The safety plan should include triggers and chain analysis of what causes these triggers to happen. You should create a list of coping skills that are available and practiced with your client—in session. Then document ways that the client agrees to reduce access to lethal means (access
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