Training and Consulting Services

SUICIDE RISK ASSESSMENT

THE CENTRAL ISSUES

Thirty-two thousand people in the United States will commit suicide this year. Nine times that many people will try to kill themselves. While some people truly wish to end their own lives, the overwhelming majority of those who attempt and/or complete suicide do not want to die as much as they want to end a devastatingly painful situation. In other words, if they could find a way to solve or end their problems other than through suicide, they would most likely choose to go on living. The key to helping these people is identifying them before they kill themselves.

Unfortunately, this is not an easy task because there is still a great deal that we don’t know about the factors that influence people to commit suicide or how those factors come together at a particular point in time to trigger the suicidal act. Adding to this problem is the fact that suicide is a relatively rare act, so we don’t have a large sample of people whose suicides can be studied. To make matters worse, the people who can provide the best information about why people kill themselves are dead. As a result, most of the research about suicide is based on retrospective data from interviews with people who knew or interacted with the deceased. There are many problems with getting information from these kinds of informants. They may not know about important events in the suicide’s life and their reports may be biased, misinformed or simply wrong. The other way we can obtain information about people who commit suicide is by studying the group that most resembles them — suicide attempters. There are many methodological problems with using this group, the most important of which is that people who attempt suicide may be very different from those who complete suicide. In the end we are left with very limited information about the factors that lead people to suicide and poor predictive measures to determine who will commit suicide.

The suicide of a patient or a client is one of the most dreaded outcomes of clinical work; the effects can be devastating, both professionally and emotionally. As one national study reported, when clinicians lose patients to suicide, or even when a patient attempts suicide, they react in much the way they would to the death of a family member, with feelings of loss, anger, guilt and helplessness (Chemtob et al., 1988).

Perhaps no role is more stressful than that of the clinicians who are responsible for assessing a client’s risk for suicide. It is their responsibility to evaluate clients and determine what the chances are that they will kill themselves. While no one can actually predict whether a person will kill himself — we can only determine where a person lies on the continuum of risk at a given point in time — if a clinician is wrong in his assessment of risk, a patient may die. In fact, evaluating individuals for suicide risk is one of the few occasions when mental health providers have to make decisions that can have immediate life- or-death consequences. In a definite understatement, one researcher commented that "the management of suicidal patients may be a higher risk professional endeavor than most other clinical situations" (Bongar, 1993).

Contrary to what many people think, client/patient suicide is not a rare event in the careers of mental health professionals. Recent empirical findings show that the average psychologist who works directly with patients has more than a 1 in 5 chance of suffering the blow of patient suicide. For psychiatrists, there is a startling 50 percent chance that a patient will commit suicide (Bongar, 1993), and even for psychiatric residents, patient suicide has been described as a "common, if not universal part" of their residency (Henn, 1978). Another study reported that psychologists in graduate clinical programs have a 1 in 7 chance of encountering a suicide during their training (Brown, 1987). As one group of researchers summed it up: "it is not a matter of whether one [of their patients] will someday commit suicide but of when" (Fremouw et al., 1990). The time has come "to outwardly acknowledge patient suicide as an important occupational hazard" (Chemtob et al., 1989).

To further complicate matters, today in the United States, we have no accepted and established national standards of care that provide practitioners with clear direction on what constitutes adequate care. And despite this need, there have been few serious efforts by professional organizations and institutions of higher education to develop techniques that would improve our ability to identify and assist those who are suicidal. Professional groups are hesitant to establish specific standards and guidelines for suicide assessment (and for other similar clinical tasks) partly because they are afraid that it would infringe on and restrict practitioners’ freedom to be exercise their personal clinical judgment and to be innovative when they are treating clients. Another reason for this hesitance to set standards stems from the resistance by medical malpractice defense lawyers who argue that it is much more difficult to defend practitioners who violate an explicit standard of care. While these attempts to protect practitioners are laudable, terrible confusion and problems have arisen because legal standards have been developed but there are no corresponding mental health standards.

With no accepted standards or guidelines, the criteria for performing suicide assessments are left to the discretion of each individual practitioner or, in legally disputed cases, to the courts. One problem with legally disputed suicide cases is that even though there are legal standards (e.g., providing a minimum standard of care), expert witnesses and attorneys can argue for "standards" of their own. For example, an expert witness may insist that an assessment was substandard because the practitioner did not use a particular procedure that the witness claims is "essential." Without professionally accepted standards of care to serve as guidelines, the judge or jury may take the expert’s word that the procedure was indeed "essential." To make matters worse, both sides use their own expert witnesses who seldom agree with each other. Inconsistent at best and chaotic at worst, for the practitioner being sued, this legal process is like having a root canal without anesthetic.

Compounding the problem is the fact that practical training in suicide assessment and management in most graduate programs is limited, and what little there is is terribly inadequate (Bongar and Harmatz, 1989; Bongar, 1992). Less than a decade ago, it was reported that only 35 percent of graduate programs in clinical psychology offered any formal training in the study of suicide (Bongar and Harmatz, 1989), and the situation is probably even worse today. This is also true as well for the other core mental health professions. One study reported that there is little routine formal training in psychiatric residency and nursing programs and schools of social work (Berman, 1986). Furthermore, a more recent study has shown that formal training in suicide is offered in only one half of the accredited undergraduate nursing programs (Bongar, 1993).

My own experience with new graduates is that even after many years of higher education, followed by internship or practicum experiences, they still seem minimally prepared for assessing suicidality — probably the most important clinical decision they will be asked to make. Of added concern is that most graduate programs seem to pay little or no attention risk management, putting students and new graduates at a distinct disadvantage when it comes to conducting legally safe suicide assessments. Not only is graduate training limited, but it can also be difficult to get additional training in suicide assessment and management training after graduation. Individuals who feel they need additional training are forced to pick and choose from an array of conflicting sources of information, various schools of thought and a narrow range of research findings. From these sources they must glean what they can and try to apply it clinically. This virtually ensures that there will be tremendous diversity among practicing clinicians concerning even the most basic aspects of suicide assessment.

As managed care and other cost-containment efforts become the driving force behind the provision of many social services, professionals without doctorates (for example, nurses, drug and alcohol counselors, therapists, student advisors and correctional workers) will have to play an even larger role in the delivery of services, shouldering clinical responsibilities for which they are minimally prepared. For these practitioners, formal training is even less available than it is for those with doctorates. Because they are often the first to come into contact with potentially suicidal individuals, they will have to make assessment decisions with little or no practical knowledge. This is not only unfair to them; it can be fatal to their clients.

Perhaps one of the most serious hazards of working with potentially suicidal clients is the threat of litigation. Malpractice lawsuits against mental health professionals have skyrocketed over the last 20 years — and the failure to prevent suicide is the most common cause of litigation against all mental health disciplines including doctors, nurses, psychologists and social workers. As a result, clinicians must not only deal with the extraordinary emotional pain that can arise when one of their clients kills himself, but now they must also worry about the very real possibility of being sued. And this is not an exaggerated concern. In a five-year analysis of lawsuits brought against psychiatrists, there were more claims resulting from the suicide of a patient than from any other cause, and these lawsuits resulted in the largest financial settlements (Robertson, 1988).

Furthermore, any mental health care provider can be sued at any time, for any case, regardless of the actual merits of the case and regardless of the quality of his performance during the assessment. In the courtroom, the plaintiff’s attorney is free to challenge every aspect of the assessment to prove their claim. Not only will a clinician’s determination of a client’s suicide risk be investigated, but so will the processes and methods he used to reach it. In fact, the methods he used to reach his conclusions about risk are probably more important. Because the court realizes that practitioners cannot actually predict who will or will not commit suicide, the central legal question is not whether the practitioner was right or wrong but whether he arrived at his determination logically, using accepted professional practices.

In light of the increasing likelihood of litigation against mental health care workers in cases of completed suicide, it is surprising that so many practitioners remain uninformed about even the most fundamental legal concepts that pertain to their practice. Even though the changes that have occurred in the legal system regarding mental health providers are intimidating and the cause of a great deal of stress, it would be unfair to say that practitioners are always hapless victims of the legal system. In fact, they are often their own worst enemies, actually causing many of the difficulties they encounter in the courtroom. Instead of taking a systematic approach to determining suicide risk that is based on a combination of objective data and reasoned judgment, practitioners often make the mistake of using idiosyncratic procedures that are guided primarily by their personal ideas, assumptions and theoretical orientations. This approach leaves them wide open to the courtroom skills of fast-talking attorneys and expert witnesses who can easily dispute the procedures they followed and the conclusions they reached.

To protect themselves, practitioners must become familiar with the legal principles that affect their clinical activities. They must learn how to conduct suicide assessments that are clinically sound and at the same time within the legal standards. Unfortunately, this is easier said than done. There is not a great wealth of information on the legal aspects of working with suicidal clients and much of the material that does exist is written for lawyers, is narrowly focused and lacks practical application. To analyze and apply the information clinically requires an investment of time and energy that most practicing clinicians do not have.