Yesterday I had a chance to do a 3-hour online workshop with a very cool group of about 22 smart, skilled, and dedicated professionals. They engaged with the content and consequently, we had some great discussions. One of the discussions has kept percolating for me today. The topic: How do we handle situations where clients are clearly suicidal, but are reluctant or unwilling to develop and agree to a collaborative safety plan.  

We talked about how, often, the knee-jerk impulse is to pursue hospitalization. While that’s a viable and reasonable option, the problem is that hospitalization and discharge is a notable risk factor for death by suicide. The other problem is that it’s pretty much impossible for us to know if the client’s resistance to a safety plan indicates increased risk, or just resistance to what s/he/they view as a coercive mandate.

There’s no perfect clinician response to this dilemma. Hospitalization helps some clients, and causes demoralization and regression in others. Not hospitalizing can feel too risky for practitioners.

We talked about a few guidelines in dealing with this conundrum. They include: (a) consulting with colleagues, (b) reflecting on the client’s engagement in other aspects of treatment (increased engagement in treatment is a protective factor), (c) evaluating client intent and client impulsivity, and (d) documenting your decision-making process (including citations indicating that psychiatric hospitalization may not be the best alternative). But again, there’s no perfect guideline.

Below is an excerpt from a CEU course I wrote about a year ago. For the whole CEU (actually there are two different CE courses), you can check out this link: https://www.continuingedcourses.net/active/courses/course114.php

Similar content is also in our brand new Clinical Interviewing textbook: https://www.wiley.com/en-cn/Clinical+Interviewing%2C+7th+Edition-p-9781119981992

Here’s the CEU excerpt:

Decision-Making Dilemmas

When discussing Kate’s situation and other scenarios that involve outpatient work with highly suicidal clients, the following question usually comes up, “What if your judgment is wrong and she either makes a suicide attempt, or she kills herself before your next session?” This is a great question and gets to the core of practitioner anxiety.

The answer is that, yes, she could kill herself, and if she does, I’ll feel terrible about my clinical judgment. Also, I might get sued. And, if I’m inclined toward suicidal thoughts myself, Kate killing herself might precipitate a suicidal crisis in me. Sometimes suicide tragedies happen, and sometimes we will feel like the tragedy was our fault and that we should have or could have prevented it. That said, most suicides are more or less unpredictable. Even if you think you’re correct in categorizing someone as high or low risk, chances are you’ll be wrong; many high-risk clients don’t die by suicide and some low-risk clients do (see Sommers-Flanagan, 2021, for a personal essay on coping with the death of a client to suicide; https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility).

More depressing is the reality that hospitalization – the main therapeutic option we turn to when clients are highly suicidal – isn’t very effective at treating suicidality and preventing suicide (Large & Kapur, 2018). Hospitalization sometimes causes clients to regress and destabilize, and suicide risk is often higher after hospitalization (Kessler et al., 2020). Because hospitalization isn’t a good fit for many clients who are suicidal and because we can’t predict suicide very well anyway, some cutting edge suicide researchers recommend intensive safety planning as a viable (and often preferred) alternative to hospitalization. In the case of Kate, as long as she’s willing to collaborate, and I’m able to contact her husband, and we can construct a plan that provides safety, then I’m on solid professional ground (or at least as solid as professional ground gets when working with highly suicidal clients).

Kessler, R. C., Bossarte, R. M., Luedtke, A., Zaslavsky, A. M., & Zubizarreta, J. R. (2020). Suicide prediction models: A critical review of recent research with recommendations for the way forward. Molecular Psychiatry, 25(1), 168-179. doi:http://dx.doi.org/10.1038/s41380-019-0531-0

Large, M. M., & Kapur, N. (2018). Psychiatric hospitalisation and the risk of suicide. The British Journal of Psychiatry, 212(5), 269-273.

Sommers-Flanagan, J. (2021, July/August). The myth of infallibility: A therapist comes to terms with a client suicide. Psychotherapy Networker. https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility

And here’s an excerpt from Clinical Interviewing.

Collaborate with Clients Who Are Suicidal

The idea that healthcare professionals must take an authoritarian role when evaluating and treating suicidal clients has proven problematic (Konrad & Jobes, 2011). Authoritarian clinicians can activate oppositional or resistant behaviors (Miller & Rollnick, 2013). If you try arguing clients out of suicidal thoughts and impulses, they may shut down and become less open.

For decades, no-suicide contracts were a standard practice for suicide prevention and intervention (Drye et al., 1973). These contracts consisted of signed statements such as: “I promise not to commit suicide between my medical appointments.” In a fascinating turn of events, during the 1990s, no-suicide contracts came under fire as (a) coercive and (b) as focusing more on practitioner liability than client well-being (Edwards & Sachmann, 2010; Rudd et al., 2006). Suicide experts no longer advocate using no-suicide contracts.

Instead, collaborative approaches to working with suicidal clients are strongly recommended. One such approach is the collaborative assessment and management of suicide (CAMS; Jobes, 2016). CAMS emphasizes suicide assessment and intervention as a humane encounter honoring clients as experts regarding their suicidal thoughts, feelings, and situation. Jobes and colleagues (2007) wrote:

CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts.” (p. 285)