You’re listening to a client describe very specific plans to attempt suicide by overdosing. She has 94 pills of a potentially lethal medication at home. She knows the number because she has counted, again and again, in a sort of ritual to prepare herself for the act.
A familiar unease settles in you. You ask her if what she is describing are merely thoughts, or plans. That is, does she really intend to actually attempt suicide very soon?
“Yes, yes,” she says quietly, sobbing. “I just don’t want to live anymore.”
You invite her to tell you more about her situation, her pain, her plans. She tells you she will take the pills tonight and that nothing will deter her. You probe for ambivalence, hope, desire to live. There is none. She says she is beyond hope or help. She is insistent on killing herself that evening in a motel room out of town, so that she won’t be interrupted.
Eventually you say you believe she needs to be in a hospital to ensure her safety.
“I would die before going to a hospital,” she says.
She then tells you that if you do anything to make her go to a hospital, then if she does survive, she will quit therapy and hate you forever, because you will have shattered her trust.
What next?
Psychotherapists, Suicidal Clients, and Psychiatric Hospitalization
A very difficult tension exists for therapists when working with a client at high risk for suicide. On the one hand, we want to provide a safe space for people to reveal their deepest thoughts without judgment. Our goal is for clients to be understood, safe, and, above all, helped.
On the other hand, if a person’s statements indicate that the person is at imminent risk of suicide, then we may need to move beyond supportive, nonjudgmental listening. We may need to take action – whether the client wants us to or not.
Let me first emphasize this: The person needs to be at very high risk of dying within minutes or hours to justify involuntary treatment, and involuntary treatment should be an absolute last resort. More on that later.
Some clients at imminent risk of suicide will recognize that they need to be in a safe environment. These clients will go willingly, perhaps even gratefully, for an evaluation. They may even appreciate receiving intensive treatment (if the hospital provides it) and having a refuge from their problems for a bit.
But when severely suicidal clients resist our efforts to keep them safe, we risk moving from ally to adversary. We now are in the position of potentially using the information that they shared with us to thwart their plans and, in the process, possibly limit their freedoms.
Danger of Overreacting to Clients with Suicidal Thoughts
It’s difficult to have someone involuntarily hospitalized, and appropriately so. Commitment to a psychiatric hospital is a drastic move and should be avoided unless you truly believe the person otherwise will die very soon if left to their own devices. Involuntary treatment takes away a person’s freedom, potentially harming the person’s livelihood, social relationships, and emotional state.
Commitment to a psychiatric hospital also can strain or even rupture the therapeutic relationship with a client. The client may become angry about needing to go to a hospital for an evaluation or admission. And the client may find it unsafe to ever confide again in you or, perhaps, any other mental health professional.
Finally, on top of all that, hospitalization can be traumatic. Assaults happen in hospitals. Patients sometimes are placed in physical restraints. The terms “hospital-related PTSD” and “sanctuary harm” address these harms.
For these reasons, psychotherapists must not overreact. Clients need to have a safe space in which they can talk about their suicidal thoughts without the therapist “freaking out” or moving to hospitalize when it is not actually justified.
Too often, therapists move toward hospitalization as a means to assuage their own anxiety about the client’s safety, not to meet the client’s needs. Desire to die is not enough to constitute imminent risk of suicide, the criterion in most states for involuntary hospitalization. Persistent suicidal thoughts are not enough to constitute imminent risk. Even having a plan to die by suicide is not enough.
To justify involuntary commitment for suicide risk, the therapist must judge that a client will die by suicide within minutes, hours, or at most a few days if they’re not protected.
I’ve had clients describe to me in very specific detail how they would attempt suicide. And they expressed strong desires to die. But they did not strongly intend to act on their suicidal thoughts any time soon. For them, it was necessary over many sessions to be able to talk through their suicidal wishes, to not feel so alone, to develop skills to stay safe and to find reasons to stay alive. Premature or outright unnecessary hospitalization would have been devastating.
Even so, there are times when a therapist finds it necessary to seek involuntary hospitalization for a client. And there are times when it might seem necessary, but isn’t.
In the example I began with, the suicidal client had a clear plan to die by suicide that night, intent to carry out the plan, and the lethal means to do so. For the therapist to not try to protect the client would be reckless, maybe even malpractice. In this case, the therapist had options besides involuntary hospitalization. As a couple examples, the therapist could help the client create a safety plan and enlist a significant other to help the client stay safe.
However, if the client remained adamant that she’d kill herself that night, the therapist might need to pursue involuntary hospitalization to protect the client and, not incidentally, protect their career, too.
(I should note that some states allow for terminally ill people to die by suicide without interference if they use medication prescribed for that purpose. In those cases, it would be inappropriate to try to thwart the person from dying by suicide.)
Are Therapists Adversaries to Suicidal Clients?
Earlier I wrote that we may move from ally to adversary in our efforts to keep a client safe against their wishes. The reality is that, in trying to keep an imminently dangerous client safe, we are the ally of the client’s healthy self, the part that wants to live.
When we believe that the client truly intends to act on suicidal thoughts very soon, the adversarial relationship exists only with the client’s unhealthy self, the part that wants to die.
When suicide is imminent, the client’s healthy self has become muted, cut off even from the client. The client may feel especially betrayed by our efforts to step in and keep them safe.
But they came to us for help. The client’s healthy self, that is, sought help. Our task is to help them stay safe in the most empowering, unrestricted way possible, but sometimes it’s simply not possible to avoid hospitalization if the client is to survive.
If all goes well, sometime later, they might even agree.
MOST RECENT UPDATE: October 5, 2024
© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide. Photos purchased from Fotolia.com
Stacey, you stated: “It is extremely difficult to have someone involuntarily hospitalized”.
Well, news for you in Southern New Mexico: It is EXTREMELY EASY to have someone involuntarily hospitalized, AND INVOLUNTARILY MEDICATED WITHOUT FOLLOWING LEGAL REQUIREMENTS for a judge’s signature, or even notification.
And, btw, I was told “you have no rights in this situation. Asking about rights, laws, a lawyer, were all answered “you can do that when you get out of the hospital.”
To this day, I can’t find anyone who cares about what they did to me.
Pattie,
It’s sad you had such a negative experience. I hope that you’re able to get help. Are you familiar with groups and literature for “psychiatric survivors”?
There are many websites and blogs that might be of interest to you. Here are just a couple:
Mad in America
The Antipsychiatry Coalition
An article that might be of interest:
An Open Letter to Psychiatrists and Mental Health Professionals from a Psychiatric Survivor
In addition, here are some grassroots groups that might also have resources or be resources themselves:
National Alliance on Mental Illness
https://www.nami.org/
Mental Health America
http://www.mentalhealthamerica.net/
I hope this information is helpful to you in your efforts to find healing, hope, and connection. Thanks for sharing here.
Pattie, I am so sorry. You will find many similar stories on http://www.madinamerica.com. I’d file a complaint as it’s illegal to not inform you of your legal rights while in a psych hospital. If they did it to you, they’ve likely done it to other patients too.
How to file a complaint
I got this advice from a friend
1) Write the state medical board, INCLUDING a formal complaint.
2) Write up reviews, including as much detail as you feel comfortable giving, on sites like Yelp, Healthgrades, etc.
3) Write a formal letter to the hospital: copy the patient advocate, the Patient Safety/Quality Care officer, the president and/or CEO and/or Chief of Staff of the hospital, any other customer service higher-ups that work for the hospital. You might also consider copying the hospital’s legal counsel on your complaint.
4) File a formal complaint with the Board of Health.
5) If you’re also having issues with the hospital itself, write a letter to the BBB.
And, if all else fails, contact the media. This accomplishes several things: gets word out about the disease, gets word out about the crappy care this doctor and his staff are providing, and puts all parties involved on alert status that you don’t take crap lying down.
Dr. Freedenthal, why do you assume the choices or hospitalization or no hospitalization? What about alternatives to hospitalization like peer respites (the one in New York City that opened a year or two ago is only for clients with psychosis, that particular respite does not accept non-psychotic clients ) , psychosocial residential treatment like Soteria, Windhorse, etc.? What about cognitive therapy for psychosis (there are therapists that specialize in this), or open dialogue therapy? Open dialogue therapy has an 80% success rate for first episode psychosis. https://www.madinamerica.com/2013/07/harrow-wunkerlink-open-dialogue-an-evidence-based-mandate-for-a-new-standard-of-care/
Those are all good alternatives to hospitalization for people with psychosis. However, as far as I know, those services are not equipped, by themselves, to prevent suicide in someone (psychotic or not) at imminent risk of ending their life. If you have information to the contrary, please let me know.
I will also note that, along the same lines as what you list, there are many less intensive treatments for people who are suicidal but not at imminent risk of acting on their suicidal thoughts.
Suicide is legal!
[This comment was edited to abide by the site’s Comments Policy. – SF]
Indeed it is – there is no law against suicide.
However, professional ethics and civil statutes allow for – and some people would say require – mental health professionals to intervene when someone is at imminent risk of dying by suicide. I don’t always support this expectation, but it’s the reality we deal with.
Forcibly preventing someone from killing themselves is surely the antithesis of professional ethics, regardless of their motivations.
How is it in any way ethical to forcibly remove somebody choice? To subjugate somebody’s will?
Are you suggesting that death is inherently bad, and life inherently good. And any individual who’s beliefs or desires contradict that is invalid and must be of an unsound mind?
It seems like more a problem of ingraining certain religions into medicine than of anything else.
I was involuntarily hospitalized a couple months ago. I’m still LIVID. It was the most dehumanizing, hopeless situation I’ve ever been in and I left feeling more alone than ever, because it was now quite apparent that I couldn’t be honest without the threat of being hospitalized again. My trust was betrayed, and it put a huge strain on my relationship with my parents. I don’t trust them, I barely even like them. I refused to talk to the psychiatrist who hospitalized me (he’d been seeing me for 5 years beforehand) and quit. I don’t trust anyone, I cannot ask for help, I’m trapped- because if I talk to anyone, I’ll end up back there.
Involuntary hospitalization is disgusting and borderline criminal.
Maria, I agree with you 100%!!
And this is from someone who is proactive about my condition, and has sought voluntary hospitalization!
Involuntary hospitalization is rarely necessary if we have QUALIFIED mental health professionals, which are becoming rare. A good doctor or therapist would not need to terrorize someone who is doing the right thing by talking about their feelings, and if need be, would respect their client by talking to them as an equal in terms of their thoughts. Ultimately, it’s the clients life, and the clients responsibility for their decisions.
I’m with Maria— I will never trust them again. I’ve been abused, humiliated, threatened, treated like a criminal, an animal, a lunatic, and held hostage by them one too many times!
The fact that she told you in no uncertain or ambivalent terms would indicate she actually wanted you to have her committed. If she didn’t want an intervention she could have either kept her mouth shut or denied immidiate planning making involuntary admission legally impossible (absence of serious risk of harm). The fact that she didn’t and at the same time told you she would hate you etcetera to me is clear evidence of irrationality.(unthinking, childish behaviour). Committing suicide under those circumstances would be a bad decision in my book (lack of clear headedness and rational decision making) and given your legal obligation I fully understand the decision you made.
As long as therapists can be held liable for their client’s personal decisions they have little control over like suicide (which I think is ridiculous) the ethical thing to do for a person seeking therapy is to avoid puttng their therapist or doctor in that position. Which of course makes therapy aimed at uncovering the motives that lead someone to consider self-destruction difficult unless your moral view is that suicide is always wrong under any circumstances.
That seems to be the guiding principle (I’d call it dogma since it cannot be substantiated objectively) for the mental health industry and in a way that’s fine (you’d want your therapist to go to great lengths to help you explore other options since no matter how you look at it suicide is a very grave matter with potentially devastating consequences) but not if the state grants him or her not only the power but also the responsibility to keep you alive against your will. In that sense I really don’t agree with your metaphor of a ‘healthy’ and ‘unhealthy’ self since such terms serve to disguise a moral position (anti suicide): to regard wanting to die as a sign of mental illness (whatever that may mean: I’ve read about this a lot and nowhere did I find a proper definition clearly stating what it is and isn’t) is a non sequitur (feeling depressed and committing suicide may be correlated but does not mean there’s a causal relationship) and a subjective opinion based on socio-cultural bias. To me it signifies nothing more than that the person in question has serious problems and is looking for a way to solve them.
In my mind suicide is a private matter and a decision, like most everything in life, that can be regarded as a good or a bad idea depending on the circumstances. If your life is utter excrement and you really are not able to enjoy it no matter what you try then to me it makes sense to end it. If on the other hand you are distraught, wracked with guilt, pain or despair and because of that (or complete detachment from reality as in psychosis) unable to think clearly and evaluate your options carefully (which would imply sufficient knowledge and consultation of specialists and others) then I don’t agree with it. Whether that is sufficient justification for the state to take away someone’s freedom is another matter.
Unfortunately the law does not differentiate between rational and irrational suicide: the first should be legal owing to the unalienable right a person has to his or her body and life, in the latter a case could be made the state would be acting in the person’s best interest when they intervene to preserve life. Such a provision in the law would safeguard the people’s right to self-determination, allow for the rescue of those in the middle of a mental crisis (when you feel you compelled to suicide a wise person would advise to get help and consider the matter again in a better frame of mind) and relieve professionals of the need to act as their clients’ keeper or surrogate-parent when it’s clear they’ve made a reasoned, personal decision about the issue (regardless of whether one agrees with it or not: how can anyone know what’s truly in another’s best interest?).
If there is a procedure that guarantees one the right to suicide (after having spoken with a mental health professional, been told the options, waited a few months to see whether they’d change their mind etcetera) and people still try to commit suicide on their own (that usually doesn’t bode very well for the outcome) or threatens others with it for any reason they should be committed to a mental hospital because either they’re just weak-willed folks who can’t fend for themselves or they have a serious condition that justifies forced intervention.