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
I realize that this article was printed some time ago. I was involuntarily hospitalized for what I believe to be unprofessional actions on the part of my student health services provider (the person who authorized my hospitalization did so after a three minute discussion in which I reiterated the same ideations I have been struggling with for years; the psychiatrist who certified me justified it by saying, and I quote, ‘you have not benefited from the full range of what psychiatry has to offer.’ I am now taking medical leave as a consequence of the lost study time and the trauma from the psych ward.
What are my options for legal restitution? I lost a 15K semester over this, I have MWs all over my transcript, and I will have to deferr my enterance into a 55K median starting salary profession on account of this. I have never once made an attempt on my life, and there is not a mark from self-harm on my body.
Here are some options at the bottom of this article. https://power2u.org/what-is-psychiatric-malpractice/
My advice? Don’t sue, too stressful, I’ve been through a lawsuit.
Going forward, only talk about SI with people that don’t involve the authorities. Even then, there’s always a risk that someone will break policy and call the police. There’s always a risk anytime you disclose to another person! As a result, some people’s only confidant is a diary. https://www.madinamerica.com/2018/08/deadly-serious-talking-openly-suicide/
I find this article disturbing as it promotes the ever-so-prevalent idea that the severely mentally ill shouldn’t have the right to be euthanized if they so choose. Most people in the mental health community overlook the fact that suicidal crises have much more to do than just a lack of clarity of thought from the suicidal individual. Suicidal crises often times arise from complex and strenuous circumstances which pills, talk therapy sessions, and government programs cannot always address adequately on their own or altogether [especially the latter, which is often slow to serve their consumers due to high demand]. It is sad that the US government is so oblivious to this and makes life an obligation, rather than “a right,” by not giving the mentally ill the choice to give life a chance or be euthanized. It makes the US feel more like a dictatorship, rather than, “a free country” as many people like to call it.
I’ve said this before in another post and i’ll say it again: many anti-suicide viewpoints are similar to those stupid “pro-life” arguments on banning abortion and euthanasia. In fact, the more anti-suicide arguments I read, the more I realize something: many mental health workers and organizations will claim to either be liberal or apolitical. However, their beliefs on mental health matters are strikingly similar to conservative redpilled conspiracy theory crap: their obsession with personal responsibility, tendency to minimize the role of environmental factors (like mental hospital abuse) on poor mental health in favor of blaming the individual (e.g. claiming their depression is caused by negative thoughts), the diagnosing of mental illnesses because the behaviors are “socially unacceptable” or go against the status quo, and their obsession with the sanctity of life. The mental health industry greatly benefits from capitalism. Not to also mention the “not all therapists are bad” mentality which arises when the field of psychiatry is challenged, similar to “not all cops” and “not all men.” The arguments against suicide, much like those on abortion and euthanasia are rooted in cultural and religious bias rather than being secular. Even though psychiatry critics are often accused of being right-wing, the majority of antipsychiatry publications like Mad in America are the complete opposite. it’s really sad that people who claim to be progressive will hold such regressive views on the topic of mental health, to the point that it contradicts their progressive views. They claim they’re “fighting the stigma” but in reality they’re enforcing it. It’s all so backwards that it’s just breathtaking.
NAMI is heavily funded by the drug industry. I would’ve added it to my earlier comment but I can’t figure out how to edit it.
Agree!
Dr. Stacey , ( I hope that’s okay, it’s easier than typing your last name),
NAMI is as pro psychiatry and pro forced drugging as one can get. Please don’t put them on the list.
To Stacey and Becky,
Thank you both so much for the helpful responses. It’s crazy how hard I’ve had to work to find out how to report such obvious egregious -and illegal – treatment. So, I truly appreciate the specific suggestions. In fact, many I’ve been familiar with for years, some like NAMI are part of the problem, although I did try their poorly run support group here, and want nothing to do with them. MHA has really come a long way (since NMHA), in terms of potent advocacy for autonomy and patient rights. I contacted the headquarters, had to leave a message, but I stressed the severity of the problem, and the need for a local affiliate -which I would be willing to help start, but I never got a call or response.
And it’s this site that introduced me to MadinAmerica, which is AWESOME, and I was surprised I had never run into it before.
I have followed a lot of leads from your website, Stacey, and will go through each suggestion I haven’t tried yet.
I have to say how angry I am that they’ve made this so difficult because I’m all I’ve got, and my mental conditions were so severe when I sought help, and they only made them so much worse. And now I have to figure this out by myself too. So, it’s taking me a long time, but I absolutely cannot let this go, unless or when it kills me.
And, btw, I’m not against the medical model. On the contrary, my depression did well for 16 years on Paxil and trazodone, but then things got really bad, and when I moved here, I was begging them for help! But I was totally misdiagnosed, ignored, couldn’t get a med appt for 4 months, not with a psychiatrist, and then the NP sends the police to my house to hospitalize me for not taking antipsychotics!
Becky, my first thought was how standard their procedures were with me at the hospital, as if that’s the way they treat everyone. I want the public to know exactly what these unqualified people do behind closed doors, and how cruel, corrupt and despicable the culture is here.
I came to get better, so I could get back to living. They sought to take every bit of power away from me.