What is our clinical responsibility for suicide?

If you're like me, you may be wondering whether the case of a young woman who was found guilty on Friday of involuntary manslaughter relates to our clinical work. She encouraged her boyfriend to follow through on his suicide attempt by telling him via text message to get back into his truck that was laden with carbon monoxide.

Certainly, the case has—and will have—legal implications as well as moral ones. But are there psychiatric ones?

Perhaps we will eventually learn more about the clinical care of both teenagers. So far, the news has reported that she herself had tried to commit suicide, that she had an eating disorder and had gone through six therapists. The judge in the Massachusetts trial did consider her a “youthful offender,” and her psychiatric state certainly could have affected her thinking process adversely.

Early in the teens’ two-year relationship, the young girl encouraged her boyfriend to seek treatment for his depression, but we don't yet know if he did and, if so, what that encompassed. Likely for ethical reasons of confidentiality, we may never be able to satisfy our curiosity and be able to assess the clinical care that was provided. Sometimes, enough information is available to do a psychological autopsy in a suicide.

Obviously, we should never encourage our own suicidal patients to complete suicide, even if we are doing some version of paradoxical psychotherapy. However, this case may intensify our own concerns of our clinical responsibility for patients who are suicidal. When are we and/or the system we work in responsible to any degree?

Suicide assessment

Research suggests that we are poor predictors of which patient will go on to commit suicide. We do know that many patients who surprisingly survive a serious attempt are later grateful for their survival, especially if they receive good follow-up care. Thankfully, suicide is rare among our patients, but emotionally devastating to any clinician if it happens.

Often, patients won't tell us of their intent, even if we competently inquire about it. We have to keep in mind such risk factors as anxiety, accompanying severe depression, loneliness, reduced cognitive ability, commanding auditory hallucinations and a lack of religious prohibition. Even if we assess a high risk, getting someone into a hospital who doesn't want to go there seems to be perversely difficult in the many states that legally insist upon demonstrative suicidal behavior first.

Personally, I only had one patient follow through with suicide in my 40 year career, and it happened way back in my first year of training.

How responsible was I? I still wonder at times. I know that I had limited knowledge and skills at the time, including being unable to appreciate that sudden, unexplainable improvement might be a clue for a suicide decision. Though I was never sued, there have been successful suits against clinicians and systems for patients who have committed suicide or homicide or experienced serious side effects of prescribed medication.

Sometimes, we try to use clinical contracts with patients to reassure ourselves that the patient will not commit suicide. However, even if a patient signs such a contract, it is not legally binding, nor clinically foolproof. Much more important is a positive therapeutic alliance.

Digital devices

Now, as with this case of texting relationships and pervasive bullying, as well as others in recent years, we have another area that needs our clinical attention. Traditionally, we were always supposed to ask about important relationships and, at times, bring significant others into the assessment and/or treatment, always with the patient's approval, unless we felt that a life was at risk.

Extending that time-tested clinical principle, we need to also inquire about digital relationships: online and through texting or other apps. With these, asking permission to review the content must be kept in mind as a possibility. In the case in question, did any of the girl’s therapists know of this texting relationship and what she was writing? If they did, could that have ended up helping both parties?

Recommendations

Certainly, this case in question has significant legal implications. Yet, it also may stimulate us to reassess how we evaluate any patient, including any organizational policies and procedures, but most especially our responsibility to those who are suicidal. Though we may have more to learn over time from this case and what it means for us clinically, in the meanwhile, we should be sure to:

1. Ask about and assess meaningful online and texting relationships;

2. Reconsider how we ask about and assess suicidal potential, being sure to adequately document what we have thought and done in this regard for each patient;

3. Allow clinicians enough time and continuing education to provide ethical and competent care; and

4. For any physician working in a state that allows so-called physician assisted suicide, assess the relevance of this case.