Work With Dangerous ClientsWork With Dangerous ClientsG. P. Koocher, Ph.D., ABPPG. P. Koocher, Ph.D., ABPP

Assess the Patient for: Diagnosis History of violence Demographics Availability of potential victims Access to weapons Substance abuse Stressors

Potentially Suicidal PatientsPotentially Suicidal Patients

Suicide is the most frequent mental health emergency: 1 out of 5 psychologists will lose a patient to suicide 1 out of 6.5 psychology trainees 1 out of 2 psychiatrists

There is a heavy emotional toll on both survivors and clinicians

Suicide is a frequent cause of malpractice suits 5.4% for psychology and 20% for psychiatry

Potentially Suicidal Patients Potentially Suicidal Patients -2-2

Inpatients vs. Outpatients Suicide is more frequent in a psychiatric

hospital setting. Hospitals are generally held to a higher

standard than outpatient community practitioners.

Few outpatient suicide malpractice cases go to trial.

Potentially Suicidal Patients Potentially Suicidal Patients -3-3

Standard of Care Clinician is not

expected to predict and prevent suicide.

Clinician is expected to identify elevated risk or suicide and to take reasonable protective and risk- reduction steps (where possible).

Assessing Competence in Suicide Emergencies and Treatment Licensed professionals

are expected to be able to handle emergencies.

Practitioners should develop intervention strategies.

Additional postgraduate training may be required.

Potentially Suicidal Patients Potentially Suicidal Patients -4-4

Selected Demographics of Suicidal Patients 1.4% of all deaths are suicides. Adolescents and people over 65 are the most

frequent age groups. Completion rate = male to female rate 3:1. Clinical diagnosis and suicide:

Over 90% of suicides are associated with mental disorder.

Patients with a major mental disorder are 10 times more likely to die by suicide.

Potentially Suicidal Patients Potentially Suicidal Patients -5-5

Diagnoses and Suicide Major affective illness = 15% of deaths. Schizophrenia = 10%. Patients hospitalized for alcoholism = 2-3%. Patients with personality disorders (especially

borderline personality) = 8%. Demographics

AttemptersAttempters = 10 - 20 times rate of completers Mainly female, personality disordered, multiple attempts

CompletersCompleters = 50 - 70% communicate intent in advance, chiefly to family members and significant others.

Indicators of Suicide RiskIndicators of Suicide Risk

History of prior attempts Acute perturbation Incident causing humiliation or shame Hopelessness about future (escape wish) Recent d/c from hospital (1 month/1 year) Constriction in ability to see alternatives to current

state (escape wish) Availability of lethal means Chronic medical disorder with persistent pain History of impulsive, dangerous, or self-destructive

behavior

Strategies to ConsiderStrategies to Consider

Hospitalization Strengthening the

therapeutic alliance Intensifying the

treatment Secure weapons Actively manage the

patient’s environment

Stepwise breaking of confidentiality

Warning potential victims

Additional protective actions.

Indicators of Suicide RiskIndicators of Suicide Risk

Contra Indicators to Risk Dependent children Recognition of the

pain that suicide would cause relatives and friends

Future significant positive events (e.g., wedding or birthday)

Elevated Risk Suicide is a low-base

rate event. EveryEvery patient should

be asked about present and past suicidal ideation during the initial intake evaluation. No patient is “too healthy” to ask.

Indicators of Suicide RiskIndicators of Suicide RiskAssessment When Ideation Is PresentAssessment When Ideation Is Present

Mental status Plan (including feasibility, lethality,

experimental actions, alternative plans) Severity of perturbation

Panic attacks and severe insomnia Narrowed rigid thinking

Loss of insight Inability to see alternatives to suicide

Indicators of Suicide RiskIndicators of Suicide RiskAssessment When Ideation Is PresentAssessment When Ideation Is Present

Information about prior attempts Patient’s perception of risk and ability to

contract for safety Hopelessness about the future Available lethal means Availability of working support system Suggestive behavior (intention to die/survive) Feelings about hospitalization

Indicators of Suicide RiskIndicators of Suicide RiskAssessment When Ideation Is PresentAssessment When Ideation Is Present

Psychological Testing (e.g., Beck’s Helplessness/hopelessness Scales, MMPI-2) All instruments tend to overpredict No test can predict individual cases Consider testing especially when therapist is

inexperienced or has countertransference issues Managed-care instruments may be helpful in

accessing treatment resources

Advance Preparations Advance Preparations ffor Working With Suicidal Patientsor Working With Suicidal Patients

Self-Evaluation Personal feelings about suicide Current capacity to deal with suicidal patient

Knowledge of Options and Resources Civil commitment criteria and procedures Connections to emergency crisis team, if any Connection to inpatient facilities

Relationships with hospital staff Referral process Staff privileges

Psychopharmacology knowledge base

Advance Preparations Advance Preparations For Working With Suicidal PatientsFor Working With Suicidal Patients-2-2

Develop Good Relationship With Knowledgeable Physician(s) Insist on medication evaluations Insist that medication recommendations be

followed as a condition of your continuing to provide therapy

Consult regularly with physician about prescriptions

Keep good notes on all of the above

Informed Consent With Informed Consent With Suicidal PatientsSuicidal Patients

Inform patient and family, if appropriate, or responsibility to protect.

Informed consent statement should contain notice to patient that you will break confidentially where appropriate, if necessary to protect.

“If I believe you are at risk of killing yourself as a way of escaping the emotional pain that brought you to see me, from a therapeutic and human perspective, my only treatment goal is to keep you safe and alive. If this is unacceptable to you, then we probably need to get you to another therapist.”

Support Systems Support Systems and Suicidal Patientsand Suicidal Patients

When Possible and Appropriate, Involve Significant Others in the Patient’s Treatment Pros and cons vary from person to person and

time to time. Can family members be therapeutic allies? Especially important to maintain safety between

sessions in outpatient treatment. Consider others such as clergy or friends when

family is not available. Document all, even when involvement of others is

contraindicated.

Interventions With Suicidal Interventions With Suicidal Patient: Safety ContractsPatient: Safety Contracts

Commonly used technique with potential clinical value

Not very effective risk-management strategy without strong alliance

Reliance on contract alone is rarely good practice Doubtful value when patient is impulsive,

substance abuser, or prone to decompensate or disassociate

If psychologist contracts, must be available on 24/7 basis

Interventions With Suicidal Interventions With Suicidal Patient: HospitalizationPatient: Hospitalization

Hospitalization does not “prevent” suicides. Hospitalization may be the only safe

intervention for some patients. Five potential conflicts:

Good risk management Best clinical care Managed-care perspective Patient perspective Family perspective

Interventions With Suicidal Interventions With Suicidal Patient: Outpatient CarePatient: Outpatient Care

Crisis Management Includes: Therapeutic activism Increased frequency of sessions and daily

check-ins Delay of patient’s suicidal impulses Efforts to increase hope and reasons for living Availability 24/7 or adequate backup

Clients must know backup arrangements Covering colleagues must be adequately briefed

Interventions With Suicidal Interventions With Suicidal Patient: Outpatient CarePatient: Outpatient Care-2-2

Maintain regular contact with prescribing physician

Sole focus on treatment = safety Remove lethal agents Be alert to sudden changes in behavior

Flights into health or decisions to divest Consistently involve significant others Consider day-treatment or other isolation-

reducing activities Document, document, document

The Chronically The Chronically Suicidal PatientSuicidal Patient

Extraordinarily difficult to treat

Suicide may be a part of defensive structure to escape pain

Gestures often have secondary gain or are expressions of rage

Regular consultation required

Highly stressful on clinician; manage own emotional resources

Be alert to countertransference

Don’t do it if you doubt your own competence

Avoid narcissistic feelings of personal responsibility leading to rage and burnout

Special Considerations When Special Considerations When Treating the Chronically Suicidal Treating the Chronically Suicidal PatientPatient

Conflict between ability to provide good treatment and Conflict between ability to provide good treatment and avoid abandonment (ES 4.09)avoid abandonment (ES 4.09)4.09 Terminating the Professional Relationship.(a) Psychologists do not abandon patients or clients. (See also Standard

1.25e, under Fees and Financial Arrangements.)(b) Psychologists terminate a professional relationship when it becomes

reasonably clear that the patient or client no longer needs the service, is not benefiting, or is being harmed by continued service.

(c) Prior to termination for whatever reason, except where precluded by the patient's or client's conduct, the psychologist discusses the patient's or client's views and needs, provides appropriate pretermination counseling, suggests alternative service providers as appropriate, and takes other reasonable steps to facilitate transfer of responsibility to another provider if the patient or client needs one immediately.

Special Considerations When Special Considerations When Treating the Chronically Suicidal Treating the Chronically Suicidal Patient Patient -2-2

Appropriate termination is key Consultation is necessary (with both senior

colleagues and prescribing physician) Termination during hospitalization may be

appropriate Consult with managed-care case manager

when appropriate Consider referral to group program

Record-keeping When Treating the Record-keeping When Treating the Dangerous (to Self or Others) Dangerous (to Self or Others) PatientPatient

Keeping good records is a must. NeverNever alter a record. Include discussions with managed-care company if

there is disagreement about frequency of treatment or hospitalization.

Think out loud about whether to appeal. Get records of past treatment, especially

hospitalizations. Maintain records per legal requirements (nature and

duration).

Getting Consultation on Getting Consultation on Dangerous PatientsDangerous Patients

Especially important where hospitalization is rejected by managed- care company.

Identify consultants before you need them.

Use peer consultation group.

Vicarious liability.

Arms-length, formal, paid consultation is the best protection.

Explore all contingencies and options.

Be sure your supervisees and assistants consult with you.

Postvention: After the EventPostvention: After the EventIn GeneralIn General

Self care Bereavement reactions:

mourning the patient’s death

Safer if done in personal therapy than in consultation

Be careful what you say and to whom; limit self-recrimination to confidential relationships

Post-mortem conferences Becoming a standard

practice for managed-care companies and hospitals

Can be helpful for closure

Insist on complete confidentiality protections with written assurance from company or agency attorney.

Postvention: After the EventPostvention: After the EventWith Patient’s FamilyWith Patient’s Family

Often an important risk management tool and a helpful thing to do.

Important part of therapist’s own coping.

At funeral or in giving condolences, avoid revealing your status and remain in background.

Any substantive interaction with patient’s family should be in private.

Avoid doing more than condolences until own feelings are worked through.

Be aware of confidentiality issues that survive patient’s death.

Postvention: After the EventPostvention: After the EventWith Patient’s FamilyWith Patient’s Family

Executor/heirs at law may waive privilege.

Good idea to get waiver from family With appropriate

waiver therapist may discuss case in general, but may also withhold details the patient would have wanted kept private.

Do not provide records without valid subpoena.

Demonstrate that therapist cared about patient and empathizes with loss.

Any sessions should be supportive and psychoeducational.

Postvention: After the EventPostvention: After the EventA Session With Patient’s FamilyA Session With Patient’s Family

Focus session on grieving process and its importance If treatment is needed, refer to

someone else. Survivors’ coping may include anger

at therapist. Referral may feel like abandonment.

Decision Model Decision Model per Leon VandeCreekper Leon VandeCreek

High

Low

Weak Strong

Violence Risk

Therapeutic Alliance

Build rapportInvolve significant othersHospitalize

Intensify therapy and

Manage environment

Build RapportShift focus to violence management

Break ConfidentialityBreak Confidentiality