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’ve posted on this thread many times.. if u live in California is anyone else terrified of the bill Gavin Newsome is getting ready to probably sign at the end of September. It’s called CARE COURT if u don’t know about it find out about it.. it’s terrifying. It doesn’t just affect homeless people.. if ur homeless, have mental health issues or have addiction issues be scared.. anyone familiar with Brittany Spears and the conservatorship she went threw? Please read about CARE COURT IT WILL NOT SOLVE THE HOMELESS ISSUE IN ANY WAY.. THIS BILL WOULD BE A HUMAN RIGHTS VIOLATION.
A. Rose,
I agree, I’m very concerned about this program. It’s overly coercive and, in the long run, could do more harm than good, I fear. Until we have a system set up with adequate housing, mental health services, and other resources, I question why we would force people into services that are inadequate. Of course, if their life is at stake immediately, that’s a different question – but the Care Court specifically will be for people who do *not* meet the usual criteria for involuntary hospitalization.
Thanks for sharing here!
I don’t live in California, but read about what they are doing with Care Court, and am appalled.
I’m also afraid that could spread to other states the way Kendra’s law did from NY, via the push by E. Fuller Torrey and the Treatment Advocacy Center. It has done more harm than good, so yes, I am worried.
Ihave never shared this with anyone so thank you for the space Stacey When I was 17 a few weeks shy of 18th birthday I took over does and my sister who never came to my room, came to my room, found me unconscious and I was taken to local hospital where I stayed in ICU for few days. from there I was hospitalized, Since under 18 it was not voluntary. This was supposed to be a well-respected hospital. The first 3 days they wont let you wear anything but a hospital robe and bathrobe, so you wouldn’t run away. First day I was in the shower and a nurse opened the door, no knock, nothing and told me she needed a urine sample It was not an emergency but opening the door so I was nude and vulnerable was the only cause I could find for it.
The psychiatrist was this awful person. Every meeting I sat saying nothing because I could not talk to her, and every meeting halfway through she would say “what are you thinking?” I would say “Nothing.” and she would reply “Nature abhors a vacuum” then total silence for the rest of the session. Unbeknownst to me a nurse was assigned to me for me to talk with but the nurse never told me this so whenever she sat by me we had a regular out in the world “How are you?” Fine and you? “weather’s nice huh? etc.
When iut was my birthday other patients told me the psychiatrist I was assigned to thght very bad sign if you didn’t ask for leave to celebrate with family. My family never did celebrate it and I was hurt every single year by it but I went anyway. My mother an excellent baker, had gotten a box of bakery pastries, danish mostly and there was one pizza for the 5 people there. No gifts, no cards. nothing to indicate I was wanted there. (In fact not one of them ever said “we’re glad you did;t succeed.” I went back to the hospital and she never asked me about it so I kept my mouth shut but worse than when I went in. I told her I would sign myself out the day I turned 18. She told me if I did she would tell my parents I wasn’t ready to go to college so I had tostay. Then 3 days later she releasedme, nothing on her part but a power play. Turns out she told them I could not go to the college I was intending to go to and had to attend the local University because it was closer to them (as though they wanted me closer) The diagnosis from the chart. “adjustment reaction to adolescence.”, an asinine and there’s nothing wrong with her dx which psychiatrically was true but she couldn’t;t say well hey nothing wrong with her that we found absent the suicide attempt. No the reasons were many and had to do with abuse and feeling, despite knowing I was going away to college, it would never end. so instead of help the hospital experience and the psychiatrist not only made this worse then but reinforced that I should keep my mouth shut whenever I was upset/about when I was being abused. .I apologize for the length and typos and hope this makes sense as I decided I don’t want to revisit it even in the writing of it.
Lee,
Thank you for telling your story here. That’s A LOT to carry alone. I’m so sorry you had such painful experiences. I hurt for you while reading your words; when you most needed care and compassion, people failed you. I’m glad you’re still here despite all that, and I hope things are at least a little better for you…?
More than you’ll ever know, your sharing can help other people who now won’t feel so alone. I hope you’ll continue to reach out to others about your experience.
Thanks, Stacey. Well, no things are better because abuser dead but absent that, given my chronic pain and that I am essentially alone, only a nephew in Texas as a relative who takes time to “talk’to me on twitter messaging, and visits 2 x /year. I have posted that here before believe, my family has lied to others, including their own children about me, said my disability is fake, I am a malingerer despite 14 brain surgeries against my pain by doctors of high regard (so not some bums who will operate just cause) They also lied said I tried to steal mother’s money, when they actually blackmailed me into giving it to them. Sounds bizarre thinking but their lawyer wrote me only way they would agree to keep my mother safe from the aides who had been provably stealing from her, was if I gave up the money my mother specifically left for me as she knew they, who could work and have money, would never help me. So along with the chronic pain, aloneness and loneliness, I am financially struggling, not as bad as many but at my age I need money when something happens and that I don’t have. So no things not good. Unfortunately have read too many articles on failure of suicide attempts and at this point more afraid of making things worse, no one finding me but the attempt failed and I am in trouble. Many years ago a psychiatrist, a social worker and a judge felt “rational suicide” would be “acceptable” in my case. I didn’t then because one doctor did such awful things that made my sitution worse I didn’t know if suicide would be from that or from the pain. i wish I had done it then because the fear of failure wasn’t there then. If my experience can help than it is worth the sharing (btw not sure if in post and for makes it hard for me to read I was clear that I was only in hospital for 13 days after the 4 she kept me there extra for her power play. In my case it was truly pointless. For others I think hospitalization is a good choice if it can help get them through a bad period. Involuntarily? Better to not have to go that route but sometimes someone needs an other to help them get the help they need
Lee,
You describe very well the physical and emotional pain you’re in – I’m so sorry, and I wish it were different for you. I often read and hear about the income disparity in the U.S. (and elsewhere), but what vexes me even more is the pain disparity. Some people’s lives have far more pain than others, and it’s not fair. I’m not saying others should feel more pain! I’m saying that you and others who have an extraordinary amount of suffering in your lives ought to have less of it, in a fair world. (I know, I know; life’s not fair, and all that. And that’s painful.)
I’m struck that hospitalization hurt you but you still acknowledge that it helps some, even when it’s involuntary. Of course involuntary hospitalization should be an absolute last resort, but I do think there are times when it’s necessary. Many people argue that psychiatric hospitalization (voluntary and involuntary) is unilaterally bad, without acknowledging that some people need it and even report it helped them. I hope to write more about that topic soon.
Thanks for sharing here!
I’ve been in constant pain and numbness for 18+ years from Transverse Myelitis. I wish more folks would try and wrap their heads around rational suicide.
I’m sorry you;re dealing with that. Yes, it’s frustrating that doctors can say sorry nothing more I can do about your disabling debilitating pain and they can’t help more than that by prescribing a lethal dose of meds or other form of assistance. The idea in the states that allow it, that it is only when you are 6 months away from death to have help in dying ignores that it is not always when you’re facing death that you want the help but when the pain is unbearable and you have no life to speak of. Best I can say unfortunately is I hope some day that will change (I thought of going to Belgium, other places abroad where it is allowed but the expense is way too prohibitive. Wish I had better words fo support for you
John,
The pain and numbness you describe sound awful. Chronic pain is correlated with suicidal thoughts and behavior, so I can understand your interest in rational suicide.
If you ever want to write a guest post about rational suicide, please let me know! While I don’t publish things that encourage or advocate suicide unilaterally, I’m interested in a critical look at the arguments for and against rational suicide.
Thanks for sharing here!
I am reading this article as a medical student curious to learn more about the process of involuntary hospitalization and how it affects the therapeutic relationship. How really do you tell a patient that you must involuntarily admit them to a hospital? This sounds like a very painful conversation for both parties, and one in which the suicidal patient will meet with anger, frustration, and feelings of betrayal. I appreciate the journal articles that are linked.
As more and more people are aware, many of us in the healthcare field are also afflicted by thoughts of suicide, I am also curious how the psychiatrist/psychologist/social worker approaches suicidal thoughts with these patients, who are intimately aware of what the process is like but are more apprehensive about sharing details of imminent suicidal ideation for fear of hospitalization, which is a threat to their livelihoods – many licensing organizations have questions regarding psychiatric histories and/or psychiatric hospitalizations on renewal of medical licenses. No physician would be willing to jeopardize the practice of their profession that they worked so hard for and incurred so much debt from, and entered with a genuine desire to help others. There’s just too much at risk.
That’s terrible. If anything, people should be more willing to trust a doctor who had been through the same thing as them. I think it would do wonders for helping overcome that feeling of extreme “aloneness” a person who struggles with mental health problems usually feels.
Involuntary hospitalization AKA How to legally kidnap someone and give them PTSD 101