Helping professionals such as doctors, nurses, social workers and mental health professionals are all guided by the ethical standard of confidentiality. In a nutshell, confidentiality is considering everything a client or patient shares in the session sensitive, private, privileged information, and not suitable or allowable for sharing with others –without consent. There are however exceptions to confidentiality, which may be determined by legislation, such as the Child Care and Protection Act 2004. The Act identifies who it refers to as Prescribed Persons (which include all Helping Professionals), holding them to reporting factual or suspected incidents of abuse or ill treatment of a minor. Another exception to confidentiality which as far as I know, is not on the law books, but an ethical standard, is reporting or providing protection to a client who is considered a risk to himself (and/or others).
When a client reports self harm, and specifically in this article I am referring to suicide, it is important that the Clinician determines whether the client’s suicidality is ideation or intent. What do I mean by ideation? A client who has suicidal ideation usually reports that they have thoughts of dying, or a desire to not exist anymore. While ideation is a clinical symptom that always warrants attention, it has been my experience that besides depression, clients who have thoughts of dying or a desire to not be around anymore, are facing a life situation for which a practical outworking, and flexing of effort appear ineffective. The unchanging circumstances create anxiety and emotional distress which are unbearable to the client. As such, their defence mechanism ‘drive’ chips in and a sole, likely escape of the frustration presents as absenting one’s presence from the situation, since they are seemingly powerless to do anything else. Dying becomes the only actionable ability.
While this is not the only explanation of why clients engage in suicidal ideations, I have had numerous clients who ideate about dying, and when I inform them that I might have to contact their next of kin or have them hospitalized, either of two things happen: One is that they quickly gain perspective and insist that they really don’t want to end their life, they just don’t know how to solve their problem, or on the other hand, there are clients who present with an insatiable narcissistic urge, and out of their craving for attention, say that they feel like killing themselves. Again, when I inform these clients of my ethical responsibility to ensure they do not harm themselves, their ‘need’ for attention wanes, and they all of a sudden gain insight.
These instances are however not textbook templates or applicable in every setting, but does underscore the need to be able to clinically assess and case conceptualize on an individual basis. So when then is a client intent on completing suicide? Well for starters, when we talk about suicide intent, we mean that the client or patient will likely take his /her own life if left to themselves or is unsupervised. In other words, there are enough indications based on the clinical assessment, that indicate self harm is imminent.
There are a number of questions which inform suicidal intent, but clinicians should note that the following circumstances are strong prompts for a high risk client:
- Losing a family member or friend to suicide
- Client or patient has a history of suicidal ideation or attempt/s
- Client has suffered a major loss (death of a family or friend, loss of a pet, relationship, opportunity, reputation, failing an exam etc.)
- The client or patient has recently received a terminal diagnoses
- The client or patient is baring severe self-guilt
Besides these circumstances (list not exhausted), a clinician should include in his or her assessment, the following questions, which inform whether the client has a plan, and how well developed it is:
- When will you kill yourself?a. It is ok to directly state what the client wants to do. I suggest you use the client’s words, but it is also important to allow the client to hear what they are planning to do, and hear it in plain words, not euphemism.b. This question will alert the Clinician to a likely/specific day or time of the attempt.c. Information about day or time indicates opportunity. If the client is unable to identify a day or time, this could mean they have little opportunity.
- Where will you kill yourself? a. This of course informs the location the attempt will be made. This means measures can be put in place to lessen the opportunity of being alone/unsupervised.
- How do you plan to kill yourself?a. This question speaks to the lethality of the method, and how quickly death could occur. For example, death is far swifter if a client shoots him/herself, verses he or she taking a cocktail of pills.
- Do you have access to (the means)?a. If a client does not have ease of access to a means of inflicting self harm, then the opportunity or likelihood of lethality (and death) is significantly minimized.b. Access will also inform supervision measures such as where the client is being monitored during treatment.
Following this checklist is not a guarantee that a client or patient will not attempt or complete suicide. What it does however, is provide an opportunity to respond to the hopelessness of a client, and offer treatment. The more affirmatives the client responds to, is the greater the possibility of self harm.
Written by Craig McNally, JP, Licensed Associate Counselling Psychologist