Suicide: PAIR 1

Table of Contents

The Ethics of Suicide Intervention Miriam Parent, Ph.D.. .................................................................................................................................................... 2

Suicide Prevention and Intervention with Adults Jennifer Cisney Ellers, M.A. and Eric Scalise, Ph.D.. ....................................................................................... 10

Module Three

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The Ethics of Suicide Intervention

Miriam Parent, Ph.D.

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Abstract Working with people in suicidal crisis is a very stressful and ethically complicated scenario. The ethical principles of

beneficence, non-maleficence, autonomy, justice, fidelity, and veracity are important when dealing with clients in

regard to suicide. It is important to note that laws differ in each state when it comes to duty to warn/duty to

protect and end of life legislation. There are several questions a mental health provider should ask when deciding

to break confidentiality in suicidal crisis. During ethical decision making, the mental health provider should identify

the problem and potential issues involved, know and review all ethics codes, laws, regulations and policies, obtain

consultation, consider all possible courses of action, choose what appears to be the best course and follow

through, and document the process and outcomes.

Learning Objectives

1. Participants will identify the ethical principles involved in dealing with clients in suicidal crisis.

2. Participants will understand important questions which need to be addressed when deciding to break

confidentiality in suicidal crisis.

3. Participants will explore the steps needed during ethical decision making.

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I. Introduction

A. Ethics

1. Not everyone’s passion but it does need to be our concern.

2. We must provide quality education and interventions in a way that honors God.

3. We must meet the civil and professional responsibilities that we have agreed to.

B. Working with People in Suicidal Crisis

1. Consistently ranks as one of the most stressful and ethically complicated scenarios.

2. Self-care in dealing with suicidal crisis is a major ethical responsibility.

3. Burnout is high and can lead to hurting yourself and others.

4. Daniel 6:5

Then these men said, “We will not find any ground of accusation against Daniel unless we find it

against him with regard to the law of his God.”

5. God will provide us with the wisdom and discernment we need if we seek Him.

II. Ethical Principles

A. Hippocrates

1. Beneficence – do good

2. Non-maleficence – do not harm

B. Justice

1. Equal access

2. Fairness

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3. Equality

C. Veracity

1. Integrity

2. Truthfulness

D. Autonomy

1. Self-determination – my right to choose.

2. Bedrock of informed consent.

3. In suicidal crisis, we are often faced with the dilemma of overriding someone’s autonomy.

E. Fidelity

1. Trust and confidentiality.

2. Bedrock of a mental health practice.

3. Allows people the safety to talk about their pain.

III. Competing Ethical Issues

A. Confidentiality

1. Tied to the issue of trust and fidelity.

2. Essential to any counseling relationship.

3. Clients need to know and have in writing the conditions when confidentiality may be waived or

limited.

4. Harm to self or others needs to be one of those clear limits.

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5. When dealing with suicidal crisis, we are constantly balancing confidentiality and keeping our client’s

trust with preserving life.

B. Preserving Life

1. Intervening in suicidal crisis

2. We should intervene therapeutically in ways that honor the clinical relationship.

3. When clinical interventions are insufficient, we may have to override confidentiality.

4. Example – AACC Code of Ethics

IV. Competing Legal Issues

A. Privilege/Confidentiality

1. Privilege is the right of the client to determine how and with whom information is shared.

2. Protected for mental health professionals by state and federal law.

3. Few understand the differences between the legal requirement of privilege and the ethics of

confidentiality.

B. Variable State Legislation

1. In regard to harm to self or others, state laws vary.

2. Tarasoff laws – duty to protect/duty to warn.

3. Map – states vary. Some states mandate while other states permit mental health professionals to

report.

C. Intent to Harm Criteria

1. The threat is serious.

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2. The threat is imminent.

3. The threat is doable.

4. The threat is against self or an identifiable person(s).

D. Future Trends

1. State laws are changing to reflect the debate over firearms.

NY SAFE Act (2013)

IL FOID Mental Health Reporting (2014)

2. Death with Dignity debates

V. Breaking Confidentiality in Suicidal Crisis

A. Who Holds the Legal Privilege?

1. In most cases, a minor does not hold legal privilege. The parent or legal guardian does.

2. If an adult chooses not to have the mental health professional disclose, their right to privilege is being

overridden.

B. Is There an Appropriate Informed Consent Agreement?

1. Is there a written, signed document?

2. Has this been reiterated in verbal discussion?

C. What Information is Needed to Preserve Life?

1. Limit disclosure to essentials.

2. The rest of the mental health record can remain confidential.

D. Who is in the Best Position to Intervene?

1. Sometimes it is family.

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2. Sometimes it is legal or medical authorities.

3. Custodial issues may need to be considered.

4. Be very careful with institutional involvement.

E. Is this a Mandated or Permissive Reporting Situation?

VI. Ethical Decision Making

A. Identify the Problem or Dilemma

1. Articulate the dilemma.

2. Is it an ethical, legal, professional, clinical, or spiritual issue?

B. Identify the Potential Issues Involved

C. Know and Review all Relevant Ethics Codes, Laws, Regulations, and Policies

D. Obtain Consultation

1. Consult God through prayer.

2. Consult other professionals to get a second set of eyes on the situation.

E. Consider all Possible Courses of Action and their Consequences

F. Choose what Appears to be the Best Course and Follow Through

G. Document the Process and Outcomes

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VII. Conclusion

A. Ethically

1. Be proactive.

2. Have clear, written, informed consent regarding confidentiality for every client.

B. Spiritually

1. Seek wisdom.

2. Knowledge plus discernment equals wisdom.

3. Proverbs 9:10

“The fear of the Lord is the beginning of wisdom, and the knowledge of the Holy One is

understanding.”

C. Professionally

1. Have established policies.

2. Know the general policies that are required or expected in your area.

D. Clinically

1. Care for the client.

2. Seek to do good. Do not do harm.

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Suicide Prevention and

Intervention with Adults

Jennifer Cisney Ellers, M.A.

and Eric Scalise, Ph.D.

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Abstract This lecture is critical for anyone working with adults in a caregiving setting. Participants will discover risk factors

for suicide. Key scripture and biblical examples of depression are reviewed. Definitions of prevention and

intervention will be explored. Dr. Scalise and Jennifer Cisney Ellers will describe why prevention is the best

intervention and outline protocol for suicide intervention, including the A.C.T. and S.T.O.P methods.

Learning Objectives

1. Participants will identify the definitions and the interaction of intervention and prevention of suicide.

2. Participants will explore the warning signs of both general suicide risk and imminent and imminent “danger

zone” warning signs.

3. Participants will review the A.C.T and S.T.O.P frameworks for suicide intervention.

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I. Introduction: Prevention and Intervention

A. Adult-focused Session

B. Prevention Defined

1. Prevention is both building immunity and recognizing warning signs.

2. This is crucial for anyone in a caregiving role.

3. Building resiliency.

B. Intervention Defined

1. Intervention is taking action when a person gives indications of suicidal ideation.

2. The best intervention is prevention.

3. To prevent suicide, we must know what we are looking at by being familiar with warning signs.

II. Anxiety, Depression, and Suicide Risk

A. Mental Illness

1. Mental illness goes hand in hand with suicide risk.

2. Mental illness is one of the single biggest risk factors for suicide.

B. Depression

1. People with faith often wrestle with the idea of depression.

There is a faulty believe that all anxious thoughts are due to a faith-issue or personal choice.

For some people, it is not just about having enough faith or praying enough.

2. There are biblical examples of individuals being depressed or deeply grieved.

Psalms- the “Feelings” book of the Bible

Job

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Elijah

Sometimes a spiritual “mountaintop” experience can be followed by a valley.

Jonah

David

Christ himself felt deep grief in the garden of Gethsemane

3. Depression is not the mark that one is not a true or strong Christian.

4. Recognizing depression vs. “bad days.”

Take note of the intensity.

Take note of the duration.

Take note of frequency.

Mood:

Depression

Loss of interest

Rage

Irritability

Humiliation

Anxiety

Behavior:

Fatigue

Loss of interest

Increased use of alcohol/drugs

Withdrawal/isolation from family and friends

Reckless behavior

Sleep disturbance

Saying goodbyes (visiting or calling)

Giving away possessions or finding homes for pets

Aggression

5. Endogenous Depression vs. Exogenous Depression

Endogenous Depression- brain injury, tumor, overly fatigued, postpartum depression,

metabolic factors, chemical imbalances.

Endogenous Depression is not related to the choices a person is making.

6. PTSD and other issues can lead to depression when left untreated.

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7. The spiritual side of depression.

Do not lose sight of this.

It is not always “either/or”

There can be a physical issue or traumatic event present, with spiritual warfare on top of it.

III. Risk and Protective Factors for Suicide

A. Risk Factors

1. Learned Coping Mechanisms

2. Use of Drugs or Alcohol

3. Financial Problems

4. Bipolar disorder

5. Depression

6. Extended timeframe dealing with an issue without treatment

7. Serious or Traumatic Loss

8. Lack of Support System

B. Protective Factors

1. Support systems

Social support

Face to face interactions

Feeling cared about

Social connectedness

2. Religious belief

“Be of sober spirit, be on the alert. Your adversary, the devil, prowls around like a roaring lion, seeking someone to

devour.” – 1 Peter 5:8

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II. Warning Signs

A. Talk- Ask

B. Rehearsal

C. What to Look For

1. Refusal to get connected with others

2. An inability to cry

3. Decrease work or school performance

4. Increased use of alcohol, illegal drugs, or prescription medications

5. Withdrawal and isolation

6. Reckless behavior

7. Doing things that might be construed as a goodbye

8. Death themes rising in conversation

9. A clearly depressed person suddenly becomes lighthearted

A dangerous window when anti-depressants begin to work.

The individual is still depressed, but has more energy to do something about it.

III. Protocol for Imminent Suicide Risk

A. Talk Directly

B. Suicide Intervention

1. Many models are available.

2. Other sessions in this course will show protocol for clinicians as well as lay helpers.

C. ACT

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1. A – Acknowledge - Take all indications of suicide seriously and be willing to listen.

2. C – Care – Voice concern and address issues directly – discuss plans, access to means, support.

3. T- Treatment – Referral all suicidal individuals to medical or mental health assistance.

D. S.T.O.P.

1. Specifics

2. Timing

3. Options

4. Proximity to Help

IV. “Two Suicide Stories”

A. The unknown man who jumped off the Golden Gate Bridge

1. In 2003 article on suicide at the Golden Gate Bridge in New Yorker magazine.

2. Psychiatrist Jerome Motto was quoted on the suicide that affected him most.

3. His client died by jumping from the Golden Gate Bridge.

4. Following his death – the psychiatrist went with the assistant medical examiner to the man’s

apartment.

5. He was in his 30s and lived alone.

6. He had written a suicide note.

7. The suicide note said “I’m going to walk to the bridge. If one person smiles at me on the way, I will

not jump.”

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B. The Jonny Benjamin Story

1. Jonny Benjamin – British young man in his 20s struggled with depression and mental health issues

since childhood.

2. Jonny was diagnosed with Schizoaffective Disorder.

3. He became suicidal and plan to die by jumping off Waterloo Bridge in January of 2008.

4. A stranger approached him and talked with him for about 25 minutes.

5. The stranger – Jonny did not get his name – convinced him not to take his life.

6. Years later – Jonny started a campaign to find the “Good Samaritan” who he called “Mike.”

7. Launched a social media campaign to find him in.

8. Jonny was able to find the man – named Neil – and thank him for what he did.

9. You can see that meeting on YouTube.