Suicide Prevention Lab Clinical Ethics and Risk Management: A Process Approach to Working with Suicidal Risk David A. Jobes, Ph.D., ABPP Professor of Psychology Associate Director of Clinical Training Director, Suicide Prevention Laboratory The Catholic University of America National Register of Health Service Psychologists 2019 National Practice Conference Washington, DC 11/8/19
Disclosures Funded by two NIMH grants; one AFSP grant Book royalties (APA Press and The Guilford Press) Founder and co-owner of CAMS-care, LLC (professional training and consultation)
How do we think about ethics? What are our considerations as clinicians?
Ethically Complex Cases Just when you think you have seen it all, an odd, complex, unclear, and confounded case comes along leaving you stumped and not sure how to proceed… With ethics there is almost always a way to “play it safe”— erring on the side of covering your own self interest (which may not always be in the patient’s best interest). How do you feel about working in the “gray areas” of ethical decision - making?
Overview to our ethical codes… Historically there was some professional reluctance to developing ethics codes. This attitude changed dramatically after WW II and the Nuremburg Trials. Across disciplines our ethics codes have started very generally and become more and more specific with each revision. Generally speaking, about 90% of ethical codes across mental health disciplines are essentially the same. For example, consider the oldest of the mental health ethics codes, the APA ethics…
General (Aspirational) Principles Beneficence and Nonmalfeasance Fidelity and Responsibility Integrity Justice Respect for People’s Rights and Dignity
Violation of Ethical Standards Explicit acts that violate the specific ethical guidelines of one’s profession ( e.g, any of the 10 ethical standards of APA code).
Pillar #1: Who is the Client?
A Different Ethical Question (Fisher, 2009) “Who is the client?” is too narrow of a focus for a larger ethical sensibility. Upon reflection, we have ethical obligations towards every party in a case, no matter how many. This requires identifying all relationships and related ethical obligations. The better question: “What are my ethical responsibilities to each of the parties in this case?”
Case Example: The Knife Wielding Intoxicated Student Jim was a 20-year-old alcoholic college student who was seen in the university counseling center for three sessions by a clinical psychologist for relational problems and depression. The psychologist is seeing a private practice client in his university office after hours when the session was interrupted by a campus security officer seeking out the psychologist because Jim is intoxicated and holding his RA hostage in his dorm room armed with a large hunting knife.
Pillar #2: Informed Consent Informed consent is a major focus in the professional ethics and risk management… Informed consent should be obtained as early as feasible. Consent should be a continuing process. The nature of psychotherapy should be fully disclosed. The anticipated course of treatment should be shared. Fees and financial arrangements should be fully discussed.
Informed consent continued… Involvement of any third parties should be made clear. The limits of confidentiality should be understood by the client. HIPAA and documentation considerations should be disclosed. Consent for new and untested treatments. Competency to give consent (minors/adults). Cultural sensitivity should be assured. Consent and trainee therapists.
Informed Consent Summary Sufficient information has been disclosed to make a fully informed decision about treatment. Participant was competent and consent was voluntary. Risks and benefits were fully reviewed. Put yourself in the patient’s place— what would you desire?
Case Example: Informed Consent and Malpractice A clinician was sued for malpractice (wrongful death) after a 12- year-old boy that he met for five sessions hung himself in the family garage. The plaintiffs complained that the psychotherapist failed to appropriately assess, intervene, and provide adequate treatment. At trial a brochure entitled “Welcome to My Practice” that described the scope, limits, and various procedures of his practice completely swayed the jury that the clinician had in fact provided crucial information that was directly relevant to the claims of the parents. The jury deliberated for a half hour and found the clinician “not guilty” of malpractice.
Case Example: A different kind of informed consent A psychologist boards a plane on a trip to a military installation where he is providing clinical and research consultation. His seat mate on the plan is a friendly and engaging member of the US military. The seat mate engages the psychologist in casual conversation about work life, family, sports teams, etc. While the psychologist is intent on doing some work during the flight, the seat mate continues to engage in conversation. The flight attendant comes through the cabin and the seatmate offers to buy the psychologist a drink…
Structuring “Usual and Customary” Practices Contacted for services — conduct an initial phone interview Have initial face to face consultation (1 session) Propose extended evaluation (4 sessions) Propose 4 month of optimal treatment plan Revisit treatment plan at the end of 4 months and continue another 4 month proposed treatment plan Work in 4 month intervals to ensure treatment is optimally effective Clearly terminate but offer possible booster session consultations
Mental illness pre- enlightenment… “Trephination”
“Moral Treatment” and the Asylum Movement… Dr. Philippe Pinel ordering the release of mentally ill from chains at Salpetrière an asylum for women in Paris (1795)
A one- size mindset and hospitalization… Hospital suicides: 1800/year ( Knoll, 2012) vs. 49-65/year (The Joint Commission, 2018) Highly critical views of Marsha Linehan and Matthew Large —i.e.,“Nosocomial suicides” which are suicides that are caused by hospitalization! Coyle, Shaver, and Linehan (2018) — potential iatrogenic effects of psychiatric crisis services Czyz, Berona, and King (2016) — readmission for suicidal teens significantly associated with more severe suicidal trajectory and suicide attempts Typical inpatient stay: medication and some brief group work of 5-6 days (NAMI, 2014) Hospitalization is associated with hundreds times greater risk for suicide deaths than general population (Qin & Nordentoft, 2005; Large et al., 2011). 5% of all post-discharge suicide occur within a week of discharge (Pirkota et al., 2005) 20% of all post-discharge suicides occur within one year of discharge (Desai et al., 2005) Outpatients avoid talking about suicide for fear of hospitalization (Blanchard & Farber, 2018)
A one- size mindset and medications… Mann et al (2005): Treating mood and the underlying psychiatric disorder is “…a central component of suicide prevention.” Un-replicated RCT evidence for lithium (Tondo et al., 2001) and clozapine (Meltzer et al., 2003 — only FDA approved Rx). RCT’s not finding a SSRI effect on suicide ideation/behavior: Gunnell et al (2005) Ferusson et al (2005) RCT’s that did find a SSRI effect on suicide ideation/behavior: Zisook et al (2011) Gibbons et al (2012) Ketamine’s impact on ideation Nitrous oxide? Limited RCT support for clozapine and lithium; very mixed results for SSRI’s…
Challenges to a “many - size” mindset: Status quo — despite the lack of evidence it is just too hard to change our mindset about hospitalization and medication (magical/wishful thinking) Health plans insufficiently cover effective suicide care (no suicide diagnosis) Clinician fears about losing patients and particularly the fear of malpractice litigation paralyzes providers and fosters a “better safe than sorry” defensive practice attitude Training issues (implementation/dissemination) — actually getting clinicians to use proven and effective treatments The pervasive clinical care bias being the only approach that will work The vast majority of suicidal people reject mental health care The public relations battle — the general public and the media are still insufficiently concerned about the magnitude of this major public health issue
Changing the mindset: Lived Experience
Changing the Mindset: Policy Developments 1. Identifying suicide risk 2. Stabilization Planning * National Lifeline * Lethal means safety 3. Caring contact (follow-up)
Changing the mindset: Stabilization Planning
Changing the mindset: Lifeline and lethal means safety 1) Always provide Lifeline number 2) Always discuss access to lethal means 3) Verify that means have been secured 4) Consider providing your own number
The importance of lethal means safety…
An idea that has been brewing for 24 years… Could differential assessments of different suicidal states lead to different “prescriptive” treatments?
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