Abstract
Suicide is a significant cause of preventable deaths both in the United States and world-wide. Accurate assessment of an individual’s suicidality is critical to proper care. While a number of instruments, structured interviews, and semi-structured interviews are available for suicide risk assessment, such tools may not be properly informative for acute care in crisis situations. This paper seeks to review suicide risk factors, suicidal warning signs, suicide risk assessment instruments, legal and ethical considerations for emergency civil commitments, and the application of suicide risk assessments in emergency civil commitments. We will close with considerations, discussions, and recommendations for suicidal crisis intervention.
Introduction
Someone in the United States commits suicide approximately every 17 minutes (Roberts, Monferrari, & Yeager, 2008). Worldwide, a completed suicide occurs approximately every 40 seconds (James & Gilliand, 2013). Completed suicides are considered to be one of the leading causes of preventable deaths among all most groups and stands as one of the top five causes of death, preventable or otherwise, among adolescents and young adults (Brown, 2013). Even more alarming is the knowledge that most suicide attempts do not result in death, even as previous suicide attempts are strong predictors of future deaths by suicide (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013). The U.S. Department of Health and Human Services (2003) estimated that between 300,000 and 600,000 Americans survive a suicide attempt every year. During any given year, approximately 4% of the United States population will seriously consider suicide, approximately 1% will make a plan for suicide, and about half of those will carry out their plan (James & Gilliand, 2013). In an era where high suicide rates among adolescents and young adults – notably those who are or are perceived to be lesbian, gay, bisexual, or transgender (LGBT) – are receiving noteworthy attention in the public and the media, the ability to differentiate between chronic suicidal ideation and acute suicidal behavior, and thus properly route each to the appropriate next level of mental health care, becomes a significant talking point among professionals, paraprofessionals, and laypersons alike as well as a focus of ongoing professional research.
The Dallas Independent School District encompasses over 384 square miles and is the 14th largest public school district in the United States. The district employs 19,838 employees to educate and support 158,932 students through 223 school campuses and several dozen support facilities (Dallas ISD, 2013). In 2012, this researcher conducted a double-blind, multivariate empirical analysis on a sequential series of mental health related police service calls and resulting police reports of the Dallas ISD (Texas) Police Department over a 136 day period. During the period studied, police personnel responded to 127 calls for service that involved mental health concerns at public school campuses and support facilities, with 77.2% resulting in an emergency civil commitment being completed by police personnel. A more narrow review of the entire 2011 year found that 62.5% of the calls for service resulted in an emergency civil commitment, which showed a 39.2% increase in hospitalization rate in a single year. Of the emergency civil commitments reviewed in the study, 38.0% originated from middle schools serving grades 6 through 8, 35.2% originated from high schools serving grades 9 through 12, 25.4% originated from elementary schools serving grades K through 5, and 1.4% originated from locations other than school campuses (Liebbe, 2012). The 62.5% and 77.2% commitment rates were high compared to national research along similar variables that showed an average of 12% commitment rates (Teplin, 1986; Teplin, 2000).
The use of suicide risk assessment instruments was not assessed in the 2012 study due to significant inconsistencies in the reporting of the use of such to police personnel during the period studied and the need for the study to remain double-blind. That said, this researcher has anecdotally observed an increasing trend for school-based and school-affiliated professionals, including both educational and mental health professionals, to utilize suicide risk assessment instruments as a means of differentiating between acute cases which may need emergency civil commitment to a psychiatric hospital (inpatient) and chronic cases which may receive equal, if not greater, benefit from community-based (outpatient). As such, this researcher set out to ascertain the empirical applicability of suicide risk assessment instruments in determining the need for emergency civil commitments to a psychiatric hospital for inpatient treatment.
Background
Suicide risk assessment is an examination of an individual’s suicide potential and venues for effective management of that potential (Berman, 2006). While the concept may seem simple enough, Roberts, Monferrari, and Yeager (2008) argue that “psychiatrists, social workers, and psychologists sometimes lack the training in assessing the degree of suicidality and conducting a lethality assessment” (p. 6). To properly understand suicidality and lethality, we must review theories for suicidality, factors contributing to and correlated to suicidality, current research, and areas where currently available research is lacking. For sake of thoroughness, we should also consider third-party impacts and professional liability.
There exist at least four fundamental theoretical models for suicidality. The Escape Theory attempts to describe how an individual progresses toward suicidal behavior through a six causal steps summarized as failure, self-blame, hyperawareness, negative affect, cognitive deconstruction, and irrational cognitions combined with disinhibition. A suicide attempt is then viewed as a way to escape from the negative emotions (Baumeister, 1990). The Psychache Theory holds that the goal of suicide is to escape from psychache, defined as an intolerable and painful psychological state. While defined, the particular thoughts and emotions underlying the psychache will be idiosyncratic to each person (Schneidman, 1993). The internal pressures to end the psychache and resulting anxiety causes suicidal ideation and, resultantly, suicidal behaviors (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013). The Hopelessness Theory tells us that abandoned hope for the future and despair is a proximal and sufficient cause for suicidality. This theory tends to hold where an individual has a lack of positive life events, a feeling that only negative life events will continue, and/or the individual is flawed (Abramson, Metalsky, & Alloy, Hopelessness Depression: A Theory-Based Subtype of Depression, 1989). Hopelessness has been shown to mediate between suicidality and its many risk factors (Abramson, et al., 1998). The Interpersonal Theory holds that two interpersonal states are strongly involved in suicidality. Thwarted belongingness is described as having feelings of loneliness and an absence of positive interpersonal relationships, regardless of whether that absence is perceived or actual. Perceived burdensomeness is the perception, or misperception, of being a burden on others such as family, peers, and/or society. The Interpersonal Theory tells us that an individual only requires one of the two described states for passive suicidality but both states in a stable and unchanging pattern of hopelessness for active suicidality (Joiner, et al., 2009; Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010). One or more of these theoretical models of suicidality may be applicable to a case, depending on the individual.
A number of researchers have worked to establish simplified warning sign lists that can help inform professionals as to when a suicide risk assessment is warranted whether structured, semi-structured, or informal. Roberts and Yeager (2005) offer nine critical warning signs for suicidal behavior:
- Reports of recent and drastic changes in behavior
- Reports of recent suicidal communications
- Giving away of prized possessions
- Symptoms of depression
- Expression of suicidal ideation
- Possession of a plan for suicide
- Expressions of or evidence of severe agitation
- Hallucinations related to harming self or others by psychotic persons
- Intoxication on illegal drugs and acting impulsively
The American Association of Suicidology (2013) provides a list of suicidal warning signs through the mnemonic IS PATH WARM:
Suicidal Ideation
Substance abuse
Feelings of a lack of Purpose
Anxiety and agitation
Feelings of being Trapped
Hopelessness
Withdrawal from people and/or activities
Anger
Recklessness
Mood fluctuations
Much research has been published in the area of chronic suicide risk assessment with a growing body of literature regarding the difficulties of and need for further research in the area of acute suicide risk assessment. Even with the large body of research and the number of instruments available, accurate assessment of chronic suicide risk proves to be difficult and even more so difficult when assessing acute suicide risk. Some of that difficulty can be attributed to the inherent problems with predicting a low-frequency event such as completed suicide (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013). The difficulty is compounded when focusing on acute risk of engaging in suicidal behavior. Additional complications are added when one considers the differing fundamental theories of suicide (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013).
Upwards of 50% of individuals who complete suicide are not in treatment for mental illness when they engage in suicidal behavior and those who are in treatment may not disclose their intent to commit suicide. Research regarding completed suicides indicates that 50% are made by people who are in some form of psychiatric and/or psychological treatment at the time (including community-based, outpatient, and inpatient), 10% are committed while in hospital care, and between 5% and 10% are made after discharge from hospital care (American Psychiatric Association, Workgroup on Suicidal Behaviors, 2003). Analysis of 100 patents who committed suicide while in hospital care found that 77% denied suicidal intent in their last communication with treatment staff (American Psychiatric Association, Workgroup on Suicidal Behaviors, 2003).
We must also consider the impact of suicidality on mental health professionals as a mediator, if not causal, factor in the proliferation of the use of suicide risk assessment instruments in acute cases. Even while completed suicides are considered a low-frequency event, most mental health professionals will encounter suicidality in private practice. In a meta-review, Granello (2010) found that nearly three-quarters of mental health counselors had at least one client make a suicide attempt during treatment and nearly a quarter had at least one client complete a suicide. Many of the mental health professionals who experienced a client completed suicide described their experience as “the most profoundly disturbing event of their professional careers” (Hendin, Lipschitz, Maltsberger, Haas, & Wynecoop, 2000, p. 2022).
As if the combined difficulties in predicting suicide and the traumatic experience that professionals may experience if a client attempts or completes a suicide was not enough, professional liability for malpractice in mental health care has become another focus of stress and need for professional risk management. Cases such as Abille v. United States (1980), Stepakoff v. Kantar (1985), Gaido v. Weiser (1989), and Bates v. Denny (1990) have sought to legally define the reasonableness of suicide prevention measures employed by physicians and mental health professionals. Tort claims alleging a failure to act in a client’s best interests or election of an improper mode of therapy has become an issue of ethical and legal debate (Slobogin, Rai, & Reisner, 2009). Many of the largest monetary settlements and judgments in malpractice torts as well as a significant percentage of malpractice lawsuits against mental health professionals are directly related to suicides (Roberts, Monferrari, & Yeager, 2008).
Due to the potential for vicarious impact of a client’s attempted or completed suicide, many professionals – both mental health and educational – have turned to what they likely believe to be a pro-active role in suicide prevention that they also likely believe mitigates their professional liability. Such perceived pro-active measures may often include the use of emergency civil commitments intended to prevent suicide when a client’s engages in or has a notable increase in suicidal ideation. As most mental health professionals do not have the legal powers to initiate an emergency civil commitment, they will often turn to law enforcement for assistance.
Legal Considerations for Emergency Civil Commitments
Two legal approaches exist for the use of civil commitment for the involuntary treatment of mentally ill persons outside of the criminal justice system – the libertarian model and the paternalistic model. The goal of the libertarian model is to limit the impact and use of civil commitments to those persons who are highly likely to harm society if they are not restrained. The goal of the paternalistic model is to seek commitment for anyone who may benefit from involuntary treatment for mental illness. While the two have competing goals, both models have noteworthy history in the United States. Legislative action and appellate rulings since the Civil Rights Era have tended to favor the libertarian model, using phrases such as “dangerous to others or to self”, “unable to provide for his or her basic needs”, “gravely disabled”, or “likely to deteriorate” as a basis for commitment while prohibiting institutionalization where a less restrictive, community-based alternative is available (Slobogin, Rai, & Reisner, 2009).
Law enforcement professionals have become the first responders for mental health crises due to the deinstitutionalization of mental health treatment, the resulting influx of persons with severe mental illnesses into communities, and society’s reliance on law enforcement for community problem solving. While some commentators have argued that a profession other than law enforcement should become the frontline for mental health services, the common-law principles providing law enforcement’s powers to protect the community and parens patriae powers to protect individuals with disabilities who cannot protect themselves affords the foundation for law enforcement’s role in community mental health (Lamb, Weinberger, & DeCuir, 2002). Further, the often bizarre behaviors exhibited by a person with a severe mental illness during a crisis often results in the police being the first to arrive to the scene. This affords the police officers something that better trained licensed mental health professionals do not have – the police officers are there (Texas Commission on Law Enforcement Officer Standards and Education, 2009). While the physical presence at the scene is a powerful tool, law enforcement officers must be able to delineate between the punitive interests of the criminal justice system, which is arguably the foundation for their dominant function, and the preventative and protective interests of civil commitments (Slobogin, Rai, & Reisner, 2009). Law enforcement professionals responding to mental health crises generally have three available response categories including field resolution (which may or may not include a referral to community-based care), affecting an arrest for a criminal violation, or affecting an emergency civil commitment (Liebbe, 2012).
The decision to utilize an emergency civil commitment should not be made casually or lightly. The 4th Amendment of the United States Constitution describes “[the] right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized” (The Bill of Rights, 1791). Many commentators and court rulings have held that civil commitments under governmental authority trigger the 4th Amendment. The United States Supreme Court has ruled that civil commitments of any form result in a massive deprivation of personal liberty (Humphrey v. Cady, 1972). Stephen Morse (1982) commented that the goal of reducing the social consequences of incompetence is not properly served through involuntary hospitalizations of the mentally ill. When considering commitments, the state should always give objective consideration to alternatives and make decisions that best serve the interests of the individual in question, which may not necessarily coincide with the interests of the decision maker (Slobogin, Rai, & Reisner, 2009). While federal legislation and court rulings have laid a foundation for emergency civil commitments at large, the specific details of such may vary from state to state.
The State of Texas provides emergency mental health intervention powers to law enforcement officers through its legislature-enacted Health and Safety Code. A law enforcement officer may take a person into custody if the officer believes the person has a mental illness, there exists a substantial risk of serious harm to any person due to that mental illness unless the person is immediately restrained, and there is insufficient time to obtain a mental health warrant from a judge. While the law enforcement officer will usually use his own observations and judgment, the law allows for his beliefs to be formed on information from a credible person, such as a mental health professional (Texas Health and Safety Code § 573.001). If the emergency (i.e. time sensitive) circumstances previously described are not met, any person – not just a law enforcement officer – may file a written petition to a judge for a mental health warrant to be issued to a law enforcement officer for execution (Texas Health and Safety Code § 573.011). Regardless of whether the apprehension is done under the law enforcement officer’s emergency powers or by the law enforcement officer pursuant to a mental health warrant, the individual in question will not be taken to a jail or detention facility but instead will be taken to an appropriate treatment facility and held for up to 48 hours in order for a preliminary examination to be conducted by a psychiatrist and/or psychologist (Texas Health and Safety Code §§ 573.021 – 573.023).
When considering the immense powers that law enforcement officers have at their disposal in preventing a possible suicide through emergency and involuntary hospitalization, it should be no surprise that other professionals, including mental health professionals in community settings or private practice, may rely on those powers as a preventative agent when a client expresses signs of or speaks directly of suicidality. Many professionals may feel that the use of a suicide risk assessment instrument is important in determining whether or not to involve law enforcement for an emergency civil commitment.
Confidentiality and Disclosure
Mental health professionals have legal and ethical obligations to their clients to ensure confidentiality is maintained wherever possible and with limited exception. Numerous Supreme Court decisions have granted constitutional protections to privacy interests under the 1st and 4th Amendments, with specific protections to psychotherapy notes and a privilege established for communications between mental health professionals and their clients (Slobogin, Rai, & Reisner, 2009). While confidentiality is considered sacrosanct among mental health professionals, disclosure of confidential communications is often necessary to support emergency civil commitments. Such releases, however, should be limited to information necessary to support the commitment.
Licensed healthcare and mental health professionals have a legal obligation to take reasonable steps to protect individuals who are being threatened with bodily harm by a patient, which may include limited disclosure to law enforcement personnel without consent (Tarasoff v. Regents of the University of California, 1976). The Health Insurance Portability and Accountability Act of 1996 (HIPPA) privacy rule allows for the disclosure of protected health information, including psychotherapy notes, when the disclosure is “necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others and is to a person reasonably able to prevent or lessen the threat” (45 CFR §§ 164.512(j)(1)(i) and 164.512(j)(4)). As such, it is legally permissible to release protected health information to a law enforcement officer in support of an emergency civil commitment.
Educational professionals have a legal obligation to protect the privacy of education records maintained by any education agency and/or institution that receives funding from the U.S. Department of Education as per the Family Educational Rights and Privacy Act (FERPA). FERPA specifically allows for the disclosure of educational records, without the consent of the parent or adult student, for the purpose of protecting the health or safety of the student or other individuals. That exception to the general consent requirement allows for the release of salient information to law enforcement officials, public health officials, and trained medical personnel that will be involved in the care of a student (20 USC 1232, 2013; 34 CFR 99, 2013).
Mental health professionals working in both public and private practice can ethically disclose confidential information without consent in emergency situations to prevent serious, foreseeable, and imminent harm to a patient/client or other identified person (American Psychological Association’s Ethical Principles and Code of Conduct § 4.05(b)(3), 2010; American Counseling Association’s Code of Conduct § B.2.a, 2005; National Association of Social Workers’ Code of Ethics § 1.07(c), 2008; The Association for Addiction Professionals’ Code of Ethics § III(1), 2011; American School Counselor Association’s Ethical Standards for School Counselors §§ A.2.c and A.7.a, 2010).
Suicide Risk Assessment Instruments and their Effectiveness
Brown (2013) conducted a meta-review of a number of instruments designed or adapted for use in suicide risk assessment. As we are only considering acute cases of suicidality for emergency civil commitments through law enforcement a number of the instruments reviewed by Brown were not considered salient for this review. Instruments that noted an administration time of longer than 10 minutes were eliminated due to the time-sensitive needs of emergency cases. Other instruments that were designed to be used on a per-session basis, daily basis, or assessed a time period greater than one week prior were also not considered as they would be more salient to chronic suicide risk assessment. For sake of simplicity, instruments that were designed for narrow populations (such as those with a specific diagnosis, those in a narrow age group, or those in a specific culture) were also eliminated from consideration. Those eliminations left the Suicide Intent Scale (SIS), Scale for Suicide Ideation (SSI), Beck Scale for Suicidal Ideation (BSI), Modified Scale for Suicide Ideation (MSSI), and Beck Hopelessness Scale (BHS) for possible use in emergency situations.
The Suicide Intent Scale (SIS) was developed by Beck, et al. (1974; as reported by Brown, 2013) and takes approximately 10 minutes to administer. The SIS is a 15 item interviewer-administered measure of the seriousness of a person’s intent to commit suicide with two subscales for the Lethality of Intent and Planning. The instrument has good internal consistency and adequate inter-rater reliability, though the instrument’s total scale has been shown ineffective for the prediction of completed suicide. The SIS is frequently used during a suicide attempt to measure the subject’s level of intent to commit suicide (Brown, 2013).
The Scale for Suicide Ideation (SSI) was developed by Beck, et al. (1979), and takes approximately 10 minutes to administer. The SSI is a 21 item interviewer-administered scale designed to measure the subject’s attitudes, behaviors, and plans to commit suicide on the day of the interview. Of those items, 9 measure suicide preparation, 8 measure suicide motivation, 1 measures frequency of previous attempts, and 1 measures the intensity of the last attempt. The instrument has been standardized for adults in both inpatient and outpatient settings, has high internal consistency, has high inter-rater reliability, and is one of the most widely used measures for suicidal ideation. It is also one of the only instruments with research-supported predictive validity for completed suicides (Brown, 2013).
The Beck Scale for Suicidal Ideation (BSI) was developed over a decade later by Beck and Steer (1991; as reported by Brown, 2013) and takes approximately 10 minutes to administer. The BSI is a 21 item self-reported scale designed to measure a subject’s suicidal ideation over the past week and previous suicide attempts. Of those items, 5 measure the desire for death, 7 measure preparation for suicide, 4 measure actual suicidal desire, 1 measures deterrents from suicide, and 1 measures malingering. The instrument has been standardized for both adult and adolescent populations, has high internal reliability, and moderate test-retest reliability. The BSI is not as frequently used in professional settings as the SSI; however, it stands as a viable alternative for measuring suicidal ideation using a self-reporting method (Brown, 2013).
The Modified Scale for Suicide Ideation (MSSI) was developed as a revised version of the SSI by Miller, et al. (1986) for use by both professionals and paraprofessionals. The MSSI is a semi-structured interview and uses 13 items from the original SSI and 5 additional items related to intensity of ideation, courage and competency to attempt suicide, and communications about death. The MSSI is less often used than the original SSI and has drawbacks in that it does not necessarily specify between acute and chronic symptoms nor does there exist much research on its predictive validity (Brown, 2013).
The Beck Hopelessness Scale (BHS) was developed by Beck & Steer (1988; as reported by Brown, 2013) and takes approximately 5 minutes to administer. The BHS is one of the most widely used instruments to measure acute hopelessness. It has excellent internal consistency, excellent test-retest reliability, and established concurrent validity. While not designed specifically to measure suicidal ideation, recent research supports the BHS’ predictive validity for both suicide attempts and completed suicides (Brown, 2013).
While several of the suicide risk assessment instruments reviewed show promise for being useful in acute and emergency settings, the predictive validity for those measures has not been thoroughly established through research. Of the instruments reviewed, only the Scale for Suicide Ideation (SSI) and the Beck Hopelessness Scale (BHS) have any level of quantifiable predictive validity for completed suicide. The low base rate for suicide attempts and completed suicide is problematic for researching predictive validity of these instruments, and further research is needed in this area even as it may be difficult to establish strong validities (Brown, 2013). Emerging research has indicated that the frequently used suicide risk assessment instruments has greater reliability in identifying individuals who have a chronic risk for suicidal ideation while having significantly diminished reliability in identifying individuals who have an acute risk for suicidal behaviors. Due to that divergence, Hermes, et al. (2009), attempted to develop an evidence-based instrument for measuring imminent suicide risk that focused on anxiety and agitation; however, their instrument was specifically designed for inpatient settings and has not been validated for outpatient or community-based settings.
The use of structured suicide risk assessment instruments, whether alone or as the majority basis within a more detailed assessment, does not appear to be validity in acute care based on the expansive body of historical and emerging research. Such instruments may appear to have predictive validity; however, the accuracy rate of prediction of suicidal behaviors appears to be quite low. No empirical research has validated a cut-off score on measures for predicting suicide (Slobogin, Rai, & Reisner, 2009).
Research Regarding Acute (Imminent) Suicide Risk
Several myths involving suicide risk assessment may be mediating the use of instruments validated for identifying chronic suicidality for the purpose of identifying acute suicidality. In a meta-review of research into those myths, Mulder (2011) found evidence to debunk two commonly held myths regarding suicidality. First, empirical evidence has found that no single risk factor or combination of risk factors were strongly associated with suicidal behavior, including both suicide attempts and completed suicides. Second, evidence shows that people in high risk groups are only slightly more likely to die by completed suicide than people in comparatively low risk groups (Mulder, 2011).
In his review of suicide risk assessment instruments and their general lack of predictive validity, Brown (2013) emphasized that “the evaluation of a patient’s risk for suicide should never be based upon a score of a single scale” (Brown, 2013, p. 37). While currently available suicide risk assessment instruments tend to assess chronic risk better than acute risk, there exists a growing body of research regarding factors related to a person’s imminent risk for a suicide attempt or completed suicide. While noting that additional research is needed to develop an empirically based suicide risk assessment instrument for acute suicidality, Ribeiro, et al. (2013) found that a person who presents with notable social withdrawal, indicators of hyperarousal, and overt communication of intent to commit suicide were significant in assessing for imminent suicide risk.
Notable social withdrawal has been empirically validated to be an acute risk factor for suicidal behaviors through both published research and post-mortem psychological autopsies. One review found that 35% of subjects had become less talkative in the few weeks preceding their completed suicides. The review further found that 29% of subjects experienced a serious interpersonal conflict during the two days preceding their completed suicides, though the authors noted that the conflict may have been mediated by the social withdrawal (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013).
Suicidal behaviors tend to require energy and resolve, therefore complete withdrawal into depression may not be as strong of an acute risk factor as one may believe. The heightened arousal described by Ribeiro, et al. (2013) included agitation and sleep disturbances, specifically insomnia and nightmares, as potential indicators of acute risk of suicidal behaviors. The agitation may be characterized by expressions of mental anguish or turmoil combined with excessive and/or repetitive behaviors. Two reviews of completed suicides among inpatients found 76% and 87% of subjects experienced severe anxiety and/or agitation within one week prior to death. Similar reviews among incarcerated persons and people seeking emergency mental health services who completed a suicide found severe anxiety and/or agitation within one week prior to death of 70% and 90%, respectively (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013). While agitation and anxiety have been studied, Ribeiro, et al. (2013) believe that insomnia and nightmare are also important, yet underappreciated, risk factors for acute suicidal behavior that fall into the heightened arousal category.
Other Considerations
A number of studies have shown that suicide risk assessment instruments are likely to result in a number of false positives and thus over predict that individuals will commit suicide when, in fact, they will not. Overreaction to false positives by mental health professionals poses risks to rapport and trust in the existing therapeutic relationships, having the potential to damage the professional’s ability to provide effective treatment in the future (Slobogin, Rai, & Reisner, 2009). The court in Johnson v. United States (1986) commented on the false positive risk in saying that the widespread use of civil commitments for suicide prevention would result in numerous people losing their freedoms when, in fact, they were not at significant risk for suicide (Johnson v. United States, 1976).
Mulder (2011) argues that the current preoccupation with suicide risk assessments and preventative civil commitments may actually cause harm to both the individuals being assessed and the professionals conducting the assessments, that the preoccupation has created a mythology that cannot be empirically supported, and that it has empowered a culture of blame when things go wrong – i.e. a client or patient dies from a completed suicide. Mulder offers several ideas to mediate those issues. Professionals must be willing to acknowledge the limits of current scientific knowledge, the problems associated with suicide risk assessment and attempts at suicide prediction, and that mental illness alone fails to fully explain suicidal behavior. Professionals must remember that psychotherapy and medications are used because they are effective treatments and not necessarily because they reduce suicidal risk. Further, professionals must be aware of their intentions when conducting suicide risk assessments, ensuring that the best interests of the client are given the greatest focus in determining outcomes. Professionals must be cognizant not to engage in suicide risk assessments and referrals for emergency civil commitment to reduce their own anxiety and/or professional liability.
Suicide risk assessments, whether instrumental or interview based, tend to focus on suicidal ideation and risk factors associated with suicidal behavior from an ongoing and chronic perspective, not an acute and imminent perspective. As such, we need to consider diminishing the current preoccupation with suicide risk assessments as a valid test for determining whether or not to initiate a civil commitment. Certain risk factors measured in suicide risk assessments will not change from day to day or even over an individual’s lifetime. Other factors, such as suicidal ideation, may not adequately measure risk for suicidal behavior, particularly when attempting to measure acute vs. chronic risk. Further, while an emergency civil commitment may deter or prevent suicidal behavior in the short term, such interventions may not fully impact long term risk (Links, Eynam, Ball, Barr, & Rourke, 2005).
Discussion and Recommendations
Proper conduct is essential when working with a person who engages in suicidal ideation or suicidal behaviors. Considerations must be given to ethical standards, legal obligations, professional standards of care, continuity of care, rapport, and the best interests of the person when making decisions with regards to care – both immediate and long-term. Structured suicide risk assessments, particularly suicide risk assessment instruments, have use in measuring chronic, long-term risk of suicidality yet consistently fail to predict suicide attempts and/or completed suicides. As such, the use of such assessments by mental health professionals may be clinically informative but should not be the determining factor in determining whether or not to seek a civil commitment. The use of such assessments by other professionals, paraprofessionals, and laypersons would not be indicated for determining whether or not a person should be civilly committed.
In determining whether or not a person should be civilly committed for suicidality, an informal assessment of current thoughts, feelings, and plans will likely be significantly more informative than formal assessment of chronic and/or static risk factors. Professionals should not be afraid to ask directly about suicidal plans and the availability of the resources needed to carry out a suicidal plan. Informal assessments of social withdrawal, heightened arousal, agitation, and sleep disturbances should also be made through either semi-structured or unstructured interview questions. Ribeiro, et al. (2013) suggest direct assessment concerning current and/or recent intent to commit suicide, planning for suicide, and preparation for suicide are crucial to proper and thorough suicide risk assessment.
Emergency civil commitment may be avoided where risk for suicide is determined to be high and a lesser restrictive alternative path taken through the use of evidence-based crisis intervention models. Links, et al. (2005) suggest efforts that reduce impulsivity and agitation as well as interventions to counter perceived hopelessness may have significant impact. Ribeiro, et al. (2013) suggest efforts to strengthen feelings of interpersonal connection and social connection. James and Gilliand (2013) suggest that efforts to help change a person’s beliefs about their situation being inescapable, intolerable, and/or interminable be a significant goal of suicidality-focused crisis intervention. Goals for suicidal intervention should include stabilization, reduction in the acute signs of stress, and restoration of independent functioning or referral to a higher level of care, if needed (Texas Commission on Law Enforcement Officer Standards and Education, 2009). These suggestions have the potential to be utilized by professionals, paraprofessionals, and laypersons whether or not an emergency civil commitment is conducted through law enforcement personnel. Proper considerations can, and should, have a positive outcome for both the person in crisis and the professionals, paraprofessionals, and laypersons helping the person in crisis.
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