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
This was enlightening, but perhaps not in the way the author hoped. While I won’t speak for others, I will say that depriving me of my right to self-determination is an absolute non-starter. If I caught even a whiff of my therapist’s thoughts going in that direction, that would be the last session with that person.
Seeking therapy in good faith is all the patient owes a therapist, and doing so absolutely does not represent an abdication of my rights to personal liberty. Frankly, this post makes me less likely to seek therapy, even though I would never let it get to the point where my liberty was deprived to me.
My situation was at least 20 years in the making. It started when I was an ent and then went to paramedics, working in a morgue and continuously being around dead people and people dying in front of me. 3 suicidal attempts-I gave up trying. Out of the 3 mental issues I have and a handful of physical problems, I have what’s called “ passive suicidal ideation “ which means that I don’t have a reason to stay alive but I can’t kill myself either.
Dave,
Those situations are so painful – the trauma you were exposed to, your suicide attempts, and your ongoing feelings of not having a reason to stay alive. An article on this site about passive suicidal ideation might be of interest, if you haven’t already seen it: Do You Wish You Could Go to Sleep and Never Wake Up?
Thanks for sharing here. I’m certain some people have read what you wrote and now feel less alone for feeling the same way.
I actually just got out of the hospital a few days ago…I admitted myself, but at the time I was still not terribly happy with those who advised it.
That only lasted while I wasn’t myself, though. Once I leveled out I could see clearly that they had been right and most likely saved my life in a very literal sense.
Selena,
Thanks for sharing here. There are people who recognize the value of their hospitalization well after the fact, but it seems like they seldom post here! I appreciate your letting people know that it is possible to level out and recognize that your treatment was life-saving. I hope you’re doing much better now.
I haven’t checked, if I’ve previously mentioned some of the following points, which are only those which immediately sprung to mind, on reading this up-date and some of the responses.
I assume that the task of social workers in the USA is the same as that in the UK., e.g. to use and create a range of innovative services, to prevent the need for hospital admissions. The theory sounds fine but it is unusual for such services to exist. When they do, social workers may not know if the staff act with sensitivity. It may not be known, if they have the courage to challenge abuses of power, by those in more senior positions.
An example is when I had to assess, whether to compulsorily detain, a young woman in the Intensive Care Unit of the hospital where I was working. She had come very close to ending her own life. One of three consultant psychiatrists had rung me and when I walked into the ICU., he persuaded nursing and junior medical staff, to form a human barricade, so I could not get to the woman’s bed. He insisted that all I had to do was rubber stamp his decision. I reiterated in front of the other staff, what I had said to him on previous occasions, i.e. that legally I was required to make my own assessment. I refused to leave and later did make my own assessment. I agreed with the woman the best way forward, leaving her and close relatives in control. She never met with a psychiatrist again.
Some years later, that consultant appeared before the courts. It was revealed, that many women had made accusations about him but he successfully argued, that he was unfit to stand trial. However, he was placed on a register of sex offenders and another of the three consultants was imprisoned.
In December 1992, a TV documentary and national newspapers reported, that the person then in charge of the National Health Service in the UK., (a former psychiatric social worker), had not acted on formal reports over at least four years, to stop another consultant psychiatrist from forcing people to have ECT without a general anaesthetic and muscle relaxant. What was happening would meet any definition of torture.
There have been endless reports of abuse of vulnerable people by callous staff in public and commercial services. What gets overlooked, is that such individuals do not work in isolation, so many staff who would otherwise work to high standards, do not speak out.
I have put forward simple solutions to the UK parliament but those haven’t been grasped. However, it will soon consider the draft of a new law, to protect staff who do speak out, i.e. whistleblowers.
One of the most important reasons to avoid compulsory hospital detentions, is that they remove any sense of having full personal control. Emotional and social crises are invariably about having lost control over what is most crucial. So, the task of social workers and others, must be to try and find ways for those who are acutely vulnerable, to have control whenever possible. That means, being able to turn to services with known staff who will do exactly the same.
There are excellent services and we need ways to bring those to public attention. It must be made easy to know, which are good or bad or just mediocre.
Apart from vary rare circumstances, staff should see compulsory detentions as an inability or failure to provide what is really necessary.
A film which I have yet to see is The Switch from 1993. That I am reliably informed, powerfully illustrates the importance of being in control of our own lives. It is based on the true story of Larry McAfee, who became paralysed from the neck down after an accident. He wanted to end his own life but when his legal right to do was agreed by the Supreme Court of Georgia, his perspective radically changed, because he then knew and felt he had control. Note that this example was about someone who medically, was not close to dying.
Regarding dilemmas and how best to respond, a key point is as you say, “But they came … for help”.
What help did they come for? What would enable them to feel in control? Do they need to feel protected and if so, how might that be achieved, where, when, how and so on? Are appropriate services available when they are needed, day or night?
John,
Oh my gosh, the abuses (and abusers) you describe are horrific. It’s tragic that in every helping profession, some abuse occurs. Unfortunately, some people are drawn to positions of power over people who are vulnerable, and as you note some systems aren’t set up to rout out abusers. We need to do better, absolutely.
I appreciate your balanced view of mental health services — yes, abuse occurs, but so does constructive help. In fact, I’d venture to say that an extremely small percentage of service providers are abusive. I wish that small percentage didn’t do so much damage.
You’re right — good help is out there, and I hope people will try to find it. And as you note, ood help involves empowering the person, working collaboratively, and avoiding involuntary care except when there truly is no other alternative way to prevent someone from doing harm to others or ending their own life. (And even then, in the latter case, I’m ambivalent about how far we should go.)
Thanks for sharing here! I’ve valued the comments you’ve left over the years.
Just reading your response. Your belief that an “extremely small percentage of service providers are abusive” is interesting . I think you are pretty wrong on that one, from several of my own, and others experiences, I have yet to meet anyone who says “yeah, they were great when they gently deprived me of my rights to make any decisions about myself”. Rather, an involuntary order is a decision that healthcare then treat as “not seeing you as human, instead seeing you as a problem, and that you cant be trusted to do anything good for yourself, that you will try to do everything to get away from them. So, there’s a whole assumption that you are “wild” and out of control, and need to be caged, and not to be trusted. There is no care in that. And while they can treat you rough and abusively, and accuse you of trying to do things that they are only assuming you would be thinking, and together, they find it perfectly normal to be forceful. Just look at these laws about “assault on a healthcare worker”. There is no protection of the law for patients who are assaulted BY healthcare workers because its “assumed” and claimed that their abuse was provoked by the patient, and in the inequal power dynamic in hospitals, no one is going to believe the patient over their own staff, especially if there are ‘mental health issues” involved, or suggested. Its a very dangerous situation for patients who dont “comply” and I have had nurses say “you are only going to make it harder on yourself”, basically justifying any abuse I should incur after that. I have been taken to the hospital involuntarily too many times because of BAD information, which means assumptions that dive off the deep end without any basis in fact. If the person providing information about someone else is convincing, its taken as fact over anything I have ever had to say to show that I was not even thinking of suicide, that peoples assumptions can be dangerous.