Can we, as mental health professionals. endorse clients' "right to commit suicide"?

[futureapppsy2]

I was reading an article today about clinical social workers and their attitudes towards suicide assessment. The authors noted that about 7% of their participants said that they felt that they couldn't tell or ask clients not to attempt suicide because they believed that it was their ethical obligation to respect their clients' autonomy and thus their right to kill themselves. To me, knowing or even strongly suspecting that your client is suicidal and purposefully doing nothing seems like a ticket to getting your license taken away and sued. On the other hand, I do know that some people hold a very strong belief in people's autonomy in all decisions, including the right to die or right to commit suicide.

Thoughts?

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[WisNeuro]

Terminal illness with incredible pain and loss of function category, I support their right. But some would view that in a different light than what many of us see in our general practice.

Temporary mental state that can improve, it's my obligation to do what I can to protect that person's safety within the bounds of my practice. They get that information in my informed consent. If they so choose, they can exercise their right to not receive care from me. By choosing to receive my services, they have agreed that I will abide by that obligation, even if it against their wishes.

I think it's much more nuanced that simply autonomy vs non. Considering fleeting mental states, impulsivity, etc.

 

[futureapppsy2]

I agree that clients always have the right not to seek our treatment or to purposefully withold information based on our professional duties as laid out in informed consent--we aren't actually mind readers after all. However, I don't think that gives us permission to just ignore client suicidality. If your client starts talking about "going away" or "everyone being better off without them" or giving away possessions with no explanation or even explicitly saying that they want to die/kill themself and you (generic) don't follow up, that still seems like it would open you up to a potential claim of negligence. That was the type of situation being discussed in that article and why I found it so surprising.


The deminsion of fleeting versus chronic suicidality is interesting, as I've heard some arguments that SPMI that hasn't responded to treatment should be included under right to die laws if non-terminal physical illness is, as well as arguments against that.

 

[EmotRegulation]

This is an interesting topic. There's a play called 'Night, Mother by Marsha Norman (won the Pulitzer Prize for drama in 1983, and also a movie) that is about a woman who has decided to commit suicide at the end of the night. It's a short (ish) play with two characters, and near the beginning of the play the central character, Jessie, tells her mother that at the end of the night she's going to go into her room and commit suicide. The whole play is about her mother trying to talk her out of it. I've known the play longer than I've been in psychology, and although the play is really about relationships, it left in me the feeling that some people approach suicide rationally, and what right does anyone have to take that away from them?

It's taken me a long time to shift that position, mostly through recognizing the transience of emotional states and thinking a lot about the tunnel vision that people get when emotional. What can seem rational and autonomous is really the state talking ("state" used broadly to mean either momentary emotional experience or longer term episodes like a depressive episode), not the full person. Because of that, I think it is our obligation to treat the whole person, and not just give credence to the likely dysfunctional perspective the person holds at that particular time in their lives.

Terminal cases and perhaps some other small faction of cases might fit the "rationale" suicide model, and as a human being I support people's rights to do with their bodies as they choose. But as a professional it is my responsibility to be on the side of life (borrowing from DBT here). It's in situations like this where the pure Rogerian perspective falls apart for me (and with schizophrenia).

 

[deleted343839]

The authors noted that about 7% of their participants said that they felt that they couldn't tell or ask clients not to attempt suicide because they believed that it was their ethical obligation to respect their clients' autonomy and thus their right to kill themselves.

And what about their other ethical obligations? Even if you are inclined to privilege autonomy over other ethical principles, that's not the same as ignoring them.

 

[smalltownpsych]

I don't support every choice patients make. I get really frustrated with that type of thinking because it is not realistic to think that we can ever have a value neutral relationship or not influence our patients. In fact, that stance is more likely to be harmful as it is not true and thus invalidating. I care about my patients and don't want them to die and I tell them that. I also tell them that I worry about other self destructive choices that they might make. To pretend that I am okay with something that I am not okay with is not healthy and is a misuse of the Rogerian unconditional positive regard because it neglects genuineness. People also have difficulty with Linehan's non-judgmental stance or radical acceptance for similar reasons, mainly because people struggle with dialectics.

 

[Cantab109]

Can you link the article?

 

[futureapppsy2]

Can you link the article?

It's pay-walled by the here's the citation and relevant text:

Sanders, S., Ting, L., Power, J., & Jacobson, J. (2006). Social workers' views of no suicide contracts. Social Work in Mental Health, 4(4), 51-66.

"Eleven (7%) statements were made that reflected the potential ethical dilemma that resulted from the use of NSC. The concept of self-determination was a centerpiece of many social workers’ views on suicide. Social workers made comments such as the clients “have the right to commit suicide,” “there are some instances that suicide is a reasonable decision,” and “I view it as a legitimate option.” Thus, for some of the social workers, the use of NSC with clients was seen as unacceptable clinical practice. They reported that their use of NSC was “manipulative” and a technique that “did not enhance the therapeutic alliance.” Other social workers saw NSC as a direct violation to the NASW Code of Ethics due to violating a clients’ self-determination. The common view was that clients had “a right” to complete suicide regardless of the views of the social worker or agency. Additionally, it was expressed that for some clients, given their history of mental illness and trauma, suicide may be a “reasonable decision” for them."

(NSC=no-suicide contract)

 

[WisNeuro]

Hmm, I'd more raise an issue that NSC's don't really do anything to lower suicide rates, last I looked at the research.

 

[smalltownpsych]

It's pay-walled by the here's the citation and relevant text:

Sanders, S., Ting, L., Power, J., & Jacobson, J. (2006). Social workers' views of no suicide contracts. Social Work in Mental Health, 4(4), 51-66.

"Eleven (7%) statements were made that reflected the potential ethical dilemma that resulted from the use of NSC. The concept of self-determination was a centerpiece of many social workers’ views on suicide. Social workers made comments such as the clients “have the right to commit suicide,” “there are some instances that suicide is a reasonable decision,” and “I view it as a legitimate option.” Thus, for some of the social workers, the use of NSC with clients was seen as unacceptable clinical practice. They reported that their use of NSC was “manipulative” and a technique that “did not enhance the therapeutic alliance.” Other social workers saw NSC as a direct violation to the NASW Code of Ethics due to violating a clients’ self-determination. The common view was that clients had “a right” to complete suicide regardless of the views of the social worker or agency. Additionally, it was expressed that for some clients, given their history of mental illness and trauma, suicide may be a “reasonable decision” for them."

(NSC=no-suicide contract)

If someone is using a suicide contract to try to control someones behavior or thinking and sees it as a manipulation, then they are just a horrible clinician. I have never had a patient sign a useless piece of paper anyway, but I do get the patient to verbally agree to various safety plans or coping strategies and I use the strength of therapeutic rapport to assist with that and if we don't feel comfortable with that, then we lock them up. 95% of the time the patient agrees to the hold anyway because we are working together on this. That is what therapeutic rapport is all about, not just saying yes to every irrational thought a patient might have.

 

[futureapppsy2]

Hmm, I'd more raise an issue that NSC's don't really do anything to lower suicide rates, last I looked at the research.

Yes, that's definitely the major issue, but I found that the "I can't tell them not to kill themselves out of respect for their autonomy" to be an interesting angle to come up.

 

[WisNeuro]

May be anecdotal, but the SW's I have worked with tend to ally with patient's viewpoints much more readily than some other providers. They can be very resistant to my PVT failure type of reports, or the notion that complete retrograde amnesia doesn't really ever happen.

 

[deleted343839]

Thus, for some of the social workers, the use of NSC with clients was seen as unacceptable clinical practice. They reported that their use of NSC was “manipulative” and a technique that “did not enhance the therapeutic alliance.”

Funny they didn't mention "not effective" or "not evidence based."

Wonder what those individuals think of interventions that are effective for suicidality.

 

[smalltownpsych]

Funny they didn't mention "not effective" or "not evidence based."

Wonder what those individuals think of interventions that are effective for suicidality.

The whole point is that they don't believe that they should intervene so effective interventions would be even worse.

 

[deleted343839]

The whole point is that they don't believe that they should intervene so effective interventions would be even worse.

Yes, that's what I surmised. By that logic anything other than nondirective therapy is an ethical no-no.

 

[futureapppsy2]

The whole point is that they don't believe that they should intervene so effective interventions would be even worse.

Speaking of which, is there solid evidence that involuntary commitment is effective in treating suicidality? I imagine it would be a really hard thing to get through an IRB, but I've read some studies that suggest that fear of involuntary commitment may do more harm than good by indirectly promoting concealment of suicidality, and that there's significant clinician-level variation on the risk threshold needed to involuntarily commit for suicidality.

 

[temppsych123]

Speaking of which, is there solid evidence that involuntary commitment is effective in treating suicidality? I imagine it would be a really hard thing to get through an IRB, but I've read some studies that suggest that fear of involuntary commitment may do more harm than good by indirectly promoting concealment of suicidality, and that there's significant clinician-level variation on the risk threshold needed to involuntarily commit for suicidality.

Just recently saw a talk by Marsha Linehan at AAS (American Association of Suicidology) where they re-analyzed a lot of their DBT data and, based on that, she believes that one of the main reasons why DBT reduces suicide attempts and other suicidal behaviors is through the pathway of reducing hospitalizations, which she thinks can be iatrogenic. Don't think the data have been published in a way I can link to, though.

 

[WisNeuro]

Just recently saw a talk by Marsha Linehan at AAS (American Association of Suicidology) where they re-analyzed a lot of their DBT data and, based on that, she believes that one of the main reasons why DBT reduces suicide attempts and other suicidal behaviors is through the pathway of reducing hospitalizations, which she thinks can be iatrogenic. Don't think the data have been published in a way I can link to, though.

From what I recall, there is a difference between short, stabilizing hospitalizations and longer hospitalizations, and whether or not there is any meaningful treatment during the hospitalization that may impact later suicidality. Sound familiar to anyone else? Citation?

On a side note, FiveThirtyEight has a pretty good piece today on Veterans suicides, I'd recommend it, good for a lay audience.

 

[modestmousktr]

"It was expressed that for some clients, given their history of mental illness and trauma, suicide may be a “reasonable decision” for them.""


What.... the everloving........ f**ck?! "You've had a particularly rough life... yes, yes, I can see why you'd consider suicide. No, no, I probably can't help. Go forth."

 

[Ollie123]

Do I believe that "in theory" someone could make a rational decision to die due to a mental illness? Sure.

In practice, it's just too thorny an issue and ethically I am very uncomfortable with the idea I would have to make a call like that. Thus, I can't imagine actually supporting it as a clinician.

 

[WisNeuro]

Never knew that social workers were such utilitarians.

 

[PsychPhDone]

On a side note, FiveThirtyEight has a pretty good piece today on Veterans suicides, I'd recommend it, good for a lay audience.

Link please?

 

[temppsych123]

Link please?

I think WisNeuro is referring to this: http://fivethirtyeight.com/features/suicide-in-the-military/

 

[PsychPhDone]

I think WisNeuro is referring to this: http://fivethirtyeight.com/features/suicide-in-the-military/

Thanks. Their search tool wasn't getting that for some reason.