7 Ethics on the Edge: Working

with Clients Who Are

Persistently Suicidal
Derek Truscott

To save a man’s life against his will is the same as killing him.
Horace

As I entered the outpatient clinic upon returning from my lunch break, the recep-
tionist stood up nervously and beckoned me over. In hushed, conspiratorial tones she
informed me that a group of noon-hour joggers had come upon a young man sitting
on the edge of a bridge railing. They called the police, who brought him to us.
Midway through my year-long doctoral internship in clinical psychology, I was
comfortable with psychiatric emergencies and the general demands of mental health
care delivery. I did not know what challenges this new client would present, but was
confident I could figure out what to do. I walked into our waiting area where Brad1
was looking absently at the floor, flanked by two police officers. I introduced myself,
thanked the officers, and confirmed that all necessary paperwork had been com-
pleted. They left and I ushered Brad into my office.
Over the next few sessions, Brad told me how he perched on bridges “almost every
week.” He said that it “just sort of happens” and denied that he particularly wanted to
kill himself. He said it was more that he was puzzled by the fact that for most people
their life is just an accident of being alive. The immediacy of the possibility of falling
to his death fascinated him in “an intellectual sort of way” by bringing the choice to
live or die sharply into focus.
I, on the other hand, became quite beside myself with worry that I would be unable
to prevent Brad from killing himself. It was obvious to me that such a dramatic threat
of ultimate harm required a correspondingly dramatic response and that I should
know what to do. The fact that I did not left me frantic. I read everything I could get
my hands on and tried one therapeutic intervention after another, seeking desperately
to find a way to pull Brad away from death. I was afraid that my supervisor and
colleagues would realize the extent of my incompetence and so I withheld from them
the seriousness of the risk. This hampered their efforts to advise me and worsened my
isolation. During my daily commute to the clinic, I began to daydream about being
terminated from my internship after Brad killed himself and what other career
I might pursue when I was forced to leave psychology.

1
The case studies presented in this chapter are amalgamations of actual clinical cases and all names are
pseudonyms.

134

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 Working with Clients Who Are Persistently Suicidal 135

Our situation reached its climax when I got a telephone call from Brad, who had
never called me before. As usual, he was calm and rational. Unusually, he told me he
intended to jump off a particular bridge. I asked why he wanted to. He was
noncommittal. I asked him what I could do to help. He said there was nothing
anyone needed to do. I encouraged him to come and talk with me in my office
straight away. He declined, said goodbye, and hung up.
I was in a state of panic and could think of nothing to do except to call the police.
They agreed to have a patrol car drive by the bridge and see if he was there. He was,
and they brought him to our clinic. I had an unsettling experience of déjà vu as two
police officers brought him into our waiting room. This time, however, Brad
responded to my questions with a silent hostility that he had never shown before.
He offered no explanation as to why he had decided to jump or why he had called me.
It was obvious that he no longer saw me as his ally.
Our sessions continued, but Brad’s attendance became sporadic, his mood apa-
thetic, our conversations shallow. He did not offer to tell me about visiting bridges
and would change the subject if asked. When I finished my rotation a month later,
I referred Brad to another therapist. I told her about his suicide risk, but did not
elaborate on his fascination with death or how frightened and ineffective I felt.
My relief over no longer having to deal with Brad was spoiled by the nagging feeling
that I had avoided disaster through sheer luck and guilt that I had not handled his case
at all well.
Near the end of my internship, Brad’s new therapist stopped me in the hallway
to tell me that Brad had died from a drug overdose. His death was ruled
a suicide by the coroner, but my colleague did not agree. Brad had been
engaging in increasingly high-risk behaviors, including sexual promiscuity and
drug use (this was when AIDS was new and untreatable), while continuing to
deny any distress. My colleague felt sure that Brad was naive to the risks of his
actions and overdosed accidentally.
I was stunned. I made my way across the hospital grounds to the office of my
supervisor. I told him the news and that I felt I had failed Brad. I confessed how I had
not told the therapist who took over Brad’s care that his risky behavior was in fact
intended to bring him close to death. I said I was sure that my fear of being exposed
as a fraud had prevented me from seeking appropriate guidance or making a proper
referral. I said he might still be alive if I had been more honest with myself and my
colleagues about feeling so out of my depth. I began to cry and expressed my
embarrassment. Thirty years later, all I remember my supervisor saying in that
meeting is, “You should only feel embarrassed if you ever don’t cry when a client
dies.”
Psychologists face few situations that give rise to as much concern as suicide.
When a client expresses suicidal intent, we typically feel a range of negative
emotions, including anxiety, powerlessness, self-doubt, and anger (Reeve & Mintz,
2001). When a client actually takes their own life, most of us feel some combination
of shock, grief, guilt, worry, shame, betrayal, disbelief, and resentment (Hendin,
Lipschitz, Maltsberger, Haas, & Wynecoop, 2000). The experience is stressful at
best, with common responses being increased vigilance for signs of suicidal intent

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 136 Ethical Issues in Specific Settings

and avoidance of suicidal clients, and career-threatening at worst, whereby we

consider changing professions (Ellis & Patel, 2012).
These concerns are not due to inexperience, however. As many as 90 percent of
patients seen in emergency settings for psychiatric reasons report suicidal ideation
(Healy, Barry, Blow, Welsh, & Milner, 2006), with 40 percent reporting active
ideation and 20 percent a current plan (Encrenaz et al., 2012; Zisook, Goff,
Sledge, & Shuchter, 1994). Of those who attempt suicide, about 50 percent sought
mental health treatment in the previous year (Han, Compton, Gfroerer, & McKeon,
2014; Pagura, Fotti, Katz, & Sareen, 2009; Stanley, Hom, & Joiner, 2015), with
30 percent of those who kill themselves having received mental health services
during the year prior to their deaths and as many as 20 percent within the last month
(Booth & Owens, 2000; Luoma, Martin, & Pearson, 2002).
Given such high rates of suicidal ideation, intention, and behavior among those to
whom we provide services, it is no surprise that almost all psychologists (i.e.,
97 percent) report providing care to at least one client who is suicidal (and often
several) before even finishing their professional training (Kleespies, Penk, &
Forsyth, 1993). Indeed, with one in four psychologists losing a client to suicide at
some point during their careers, it has even been dubbed an “occupational hazard”
(Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989).
Psychologists are not alone in being concerned about suicide. The belief that
suicide is wrong (for various reasons) and that society has a responsibility to prevent
it has historically been the norm. The unacceptable nature of suicide is perhaps best
evidenced by the fact that ending one’s life was for a very long time a criminal
offence in most societies. Indeed, it is only in relatively recent times that suicide has
been decriminalized in many countries, and it remains a crime in some countries
(Leenaars et al., 2002).
Despite this trend among policy-makers, there are those – including
psychologists – who maintain that suicide is inherently wrong and that we
are obligated to prevent people from ending their own lives. Many who hold
such a belief justify it on religious grounds (McCormack, Clifford, & Conroy,
2012). Faith-based arguments are usually some version of the assertion that
life is a gift from God and it is an affront to His omniscience for mere mortals
to decide when our lives are no longer worth living.
Of course, many secular individuals also feel that suicide is wrong. They tend to
argue that taking one’s own life has profoundly negative effects on family, friends,
community, and society. In fact, research has shown that the family and friends of
people who have killed themselves do often experience rather profound physical and
psychological problems after the death (Cerel, Jordan, & Duberstein, 2008; Shields,
Kavanagh, & Russo, 2015; Sveen & Walby, 2008). Thus, the argument goes, the
person who ends his or her pain by suicide causes pain for others, which makes their
action immoral. Also usually implied but not stated is that because we have obliga-
tions to others, we have a duty to protect our own lives in order that we might
continue to be of service.
Sometimes psychologists will defend their feeling that they ought to prevent
a client from ending their life by highlighting that those who survive a suicide

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 Working with Clients Who Are Persistently Suicidal 137

attempt usually report relief that they failed – a secular version of the “perils of
hubris” argument of religious believers. But we know that whenever anyone makes
a difficult choice, it is common if not typical that doubts remain, such that regret in
itself does not justify us preventing others from acting on their decisions.
The select few who hold that suicide is not necessarily always wrong usually
appeal to our freedom to choose the manner and timing of our death and our rational
abilities to weigh the evidence for choosing to end – or continue – our own lives. This
perspective contains a broad range of beliefs, including suicide as an individual’s
self-indulgent right to die, a reasonable and calculated strategy for avoiding pain and
suffering, or the rational outcome of a contemplated decision that one’s life is not
worth living. Common to these views is that there exists no prima facie obligation to
prevent suicide.
Given all of this concern and controversy, many psychologists are surprised to
learn that the current professional ethical and legal standards regarding suicide
are not really all that complicated. We are expected to do what is reasonable
under the circumstances and within the limits of our professional expertise to
address whatever mental health issues are prompting our client to contemplate
suicide. We are not required to intervene in every instance to prevent someone
from killing themselves. Indeed, our primary ethical and legal obligation is to
respect our clients’ autonomy to decide what they want to do with their lives.
Preventing someone from killing themselves, provided they are competent to
make the decision, is a violation of their autonomy and thus unethical, and in
some instances is an assault and thus illegal. If our failing to take all reasonable
steps to prevent or reduce a client’s risk of suicide contributes to the client’s
death by suicide, we could be found professionally negligent. However, if we
take all reasonable steps and our client still takes his or her own life, their
suicide is not the result of our negligence.
Only when someone with whom we have a professional care relationship is
incapable of deciding whether or not to end their own life and is at risk of suicide
are we expected to intervene to prevent them from doing so. Note that the mere fact
that someone wants to end their life does not constitute sufficient evidence that they
are incompetent. Competence is decision-specific and not synonymous with mental
illness.
The courts recognize that some courses of action undertaken to prevent a suicide,
such as involving other people without the client’s permission, can be reasonable under
some circumstances, while the same action may not be reasonable in circumstances
where it will increase the likelihood that a client will kill themselves. This is why in
particular we are expected to maintain confidentiality in all but exceptional circum-
stances. Breaking confidentiality carries a high risk of being experienced as
a professional betrayal and thereby increasing the client’s risk of suicide. Only when
no other option consistent with the client’s wishes is likely to reduce their risk of killing
themselves do our professional ethics permit us to break confidentiality, which would
normally take precedence over responsible caring, but do not require us to do so.
Therefore, in some situations, such as when a person wants to kill themselves in
response to hallucinations commanding them to do so, doing everything reasonably

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 138 Ethical Issues in Specific Settings

possible to prevent their death by suicide would be considered right. In most other
circumstances, intervening to prevent someone from taking their own life would be
wrong to the extent that they are competent to decide that they want to die.
All of this is of course difficult enough in practice, if not in theory, but is made
even more difficult when a client repeatedly threatens suicide or is otherwise
persistently suicidal. Taking extraordinary steps such as scheduling extra sessions,
taking telephone calls in the middle of the night, or arranging involuntary hospita-
lization is one thing when responding to an emergency, but when a client is in
perpetual suicidal crisis, we simply cannot routinely respond in an exceptional
manner. So much time and effort ends up being spent responding to suicide that
none is left to respond to the distress giving rise to it. Of particular significance in
such situations is that our goals for the client are no longer in alignment with the
client’s for themselves. We want to stop them from taking their own life, while they
want to end their emotional pain by means of suicide. What starts out as a lack of
collaboration can become working at cross-purposes, and many therapists are left
feeling that the client is being manipulative in the service of some goal other than
seeking mental health. Such a situation does not bode well for a good outcome.
Of deeper concern for the profession is that our ethical codes and practice guidelines
are predicated on suicide as a circumscribed crisis. This has resulted in practices that
deny us access to corrective feedback with clients who are persistently suicidal. If we
intervene against a client’s wishes in a crisis situation they may be grateful, and if not
they may deny future suicidal intent in order to be left alone to do as they choose or to
discontinue treatment. In any of these situations, it is easy for us to believe that we have
done the right thing. Even if the client makes a complaint after we prevent them from
killing themselves, our colleagues, the courts, and members of a discipline committee
are very likely to be sympathetic toward us for acting to preserve life. If a client is
steadfast in their wish to die, however, our assumptions about the rightness of our
actions are brought into sharp relief and seriously questioned.
Perhaps most significantly, when a client makes repeated attempts on his or
her own life, repeatedly threatens to commit suicide, or is in a state of persistent
suicide risk, important issues regarding accepted professional practice are
raised. In particular, are we too eager to prevent suicide because we desperately
do not want it to happen for reasons of our own self-interest – avoiding the
negative emotions aroused by the threat of self-inflicted death – without fully
considering what our client wants? Are we subjugating the very person we
intend to rescue?
Because I was so afraid of, conflicted about, and categorically opposed to Brad’s
suicide, I responded unhelpfully to his threat to take his own life. I both over- and
under-reacted to his chronic suicidal state, and in so doing acted contrary to my
professional obligations as a psychologist. Brad represented an opportunity to learn
from the extreme of working with a client who was repeatedly threatening suicide
and thereby deepen my understanding of the ethics of suicide prevention. I now
know that resolving my feelings, attitudes, and understandings about suicide and
a client’s wish to die can ultimately improve the ethicality and legality of our
practice.

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 Working with Clients Who Are Persistently Suicidal 139

Assessing of Risk versus Providing Care

Caroline and I came to work together by way of a referral from her
physician. Of primary concern was that she was frequently cutting herself and
threatening suicide. As a former medical student, she knew too well how to bring
about death and had made a number of highly lethal attempts to kill herself. It was
only the fortuitous intervention of family members that had kept her alive.
From the start of our first session, Caroline manifested extreme distress. Her
whole body trembled and she fidgeted constantly in her chair. She was almost always
crying or on the verge of tears. Her appearance was unhealthy, with mottled skin,
uncombed hair, and disheveled clothing. Whenever I asked how her week had been,
she responded in a quivering voice with some variation on “awful,” “terrible,” or
“unbearable.” She avoided eye contact or even looking in my direction, as if to do so
was more than she could bear.
The intensity of Caroline’s distress was such that it was difficult to get a clear
picture of her history or current situation. I gradually pieced together that as a child
she was unwanted, unloved, and neglected, and had been sexually abused by various
men who passed through her parents’ home. She told me she had been sexually
assaulted on more than one occasion as an adult, but was vague about the details.
There was no bright spot in her life that I could find. My attempts to identify personal
strengths or interpersonal supports were met with icy disdain.
In fact, Caroline had a palpable anger that simmered beneath the surface of our
relationship, never openly expressed. She seemed to be upset with me for failing to
understand how badly she was suffering or caring enough to focus all my efforts on
her. I found it very difficult to refrain from responding with annoyance given that she
did not appear to appreciate how I was spending a disproportionate amount of time
and effort on her.
I thought about Caroline so much because I was terrified she would eventually
succeed in killing herself and I would be charged with professional incompetence.
I worked hard to offer helpful explanations for her distress and to propose interven-
tions to alleviate it. She would guardedly nod her head and then invariably return for
our next session saying, “I want to die; I want my life to end.” Seeking to protect
myself from possible litigation, I diligently devoted the end of each session to
assessing her suicide risk. Given that her history could not change and her circum-
stances were not changed, I inquired about her distress, hopelessness, and suicidal
plans. This was not well received – she would answer curtly and leave in a huff.
Caroline was rattling my belief in myself as a good therapist. I felt both irritated
with and sad for her. I questioned why she continued to seek therapy and began to
suspect that she did so to torment me. Seeing her name on my day’s schedule filled
me with dread. I found myself wondering if she might actually be better off dead, and
worried that my thinking was motivated by feeling that I might be better off if she
was dead.
Fortunately, I had learned my lesson many years ago and relied on trusted
colleagues to help keep me focused on trying to find ways to be effective. Through
our consultations, it began to dawn on me that my attempts to protect myself from

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 140 Ethical Issues in Specific Settings

accusations of malpractice were having a paradoxical effect. The more time I spent
assessing Caroline’s risk of suicide, the more upset she became with me and the more
her risk increased, which intensified my fears and prompted me to be more wary,
which intensified her distress, and so on in a vicious cycle.
I therefore decided after much soul-searching to gird my loins, set aside my fear of
litigation, and discontinue the risk assessments. For our next few meetings, Caroline
appeared suspicious when I did not finish the session with questions about her
suicidal intentions, but she soon adapted, and we put the extra time to therapeutic
use. By not focusing on protecting myself, I was able to focus on how she could
respond to her distress in healthier ways. We collaboratively developed a self-care
plan to address her chronic emotional distress and a safety plan for acute suicidal
exacerbations. She made gradual progress.
After two and a half years of psychotherapy, including nine months of termination
planning, I said goodbye to Caroline. She was still generally unhappy and thought
about suicide from time to time, but her rate of self-harming had declined to every
other month, and she had not made a suicide attempt for over a year. She contacted
me a few years later to tell me that she had married and returned to medical school.
When clients disclose thoughts of suicide, most psychologists consider a risk
assessment to be professionally indicated. If asked, however, they typically cannot
give a good explanation for doing so. Most assess their suicidal client’s risk because
they think they are expected to (for unspecified reasons) or because they feel they
should be doing something to address the suicidality and can think of nothing else to
do. Often they report a vague idea that they are somehow protecting themselves from
legal liability. It should be obvious that none of these reasons are based on sound
professional reasoning.
The greatest practical challenge with risk assessment is that suicide is a very rare
event. Even if we were able to identify those who will take their own life within
a small margin of error (an ability we do not have), we would falsely identify
a great number of people who would not go on to do so (Large, Ryan, & Nielssen,
2011). Thus, we might think that what suicide risk assessment can do is define
a group of people who are more likely to kill themselves than others when, in fact,
suicide is highly unlikely among those classified as high-risk: less than 1 percent of
those classified as high-risk end their own life (Madsen, Agerbo, Mortensen, &
Nordentoft, 2012; Steeg et al., 2012), while 40 percent of inpatient suicides (Large,
Smith, Sharma, Nielssen, & Singh, 2011) and 60 percent of suicides after discharge
(Large, Sharma, Cannon, Ryan, & Nielssen, 2011) occur among patients classified
as low-risk.
To make matters worse, while many factors identified as contributing to suicide
risk, such as psychiatric diagnosis, previous attempts, hopelessness, and lack of social
supports, have a statistically significant (small) relationship with suicide completion
(Maris, Berman, & Silverman, 2000), different studies have identified different
factors, such that there is no empirical basis for justifying our choosing which factors
to assess with any given client (Wang et al., 2015). In fact, those who attempt suicide
and those who kill themselves are, by and large, drawn from different populations
(Beautrais, 2001), with people who survive a suicide attempt tending to be young

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 Working with Clients Who Are Persistently Suicidal 141

women who make multiple attempts and those taking their own life tending to be
older men who do so on their first attempt (Encrenaz et al., 2012; Maris et al., 2000).
Most clinicians understandably but naively regard the presence of suicidal idea-
tion as a crucial factor in assessing a client’s risk of self-inflicted death, despite the
fact that expressed ideation simply does not correspond with completed suicide
(Lukaschek, Engelhardt, Baumert, & Ladwig, 2015). Suicidal ideation is only
weakly associated with future suicide among psychiatric inpatients (Large, Smith,
et al., 2011) and patients recently discharged (Large, Sharma, et al., 2011), while
70 percent of people who kill themselves had not seen a mental health professional in
the year prior to their death (Booth & Owens, 2000; Luoma, Martin, & Pearson,
2002). In one study of 67 people who died by suicide within a week of a medical
appointment, for example, only seven had disclosed suicidal thoughts to their
physician (Britton, Ilgen, Rudd, & Conner, 2012). The combination of thoughts of
self-destruction being very common among those who seek our help and the fact that
many people intent on suicide do not disclose their desire to do so renders ideation
a useless predictor (Large & Ryan, 2014).
Another reason that many psychologists provide for assessing suicide risk is their
belief that the vast majority of suicides, if not all, are a symptom of mental illness
(Pridmore, 2015). If this were true, we would identify and treat our clients’ mental
disorders and thereby reduce their risk of killing themselves. Some have argued that
it is a “kind of gospel” among mental health professionals that “anyone who
contemplates, expresses a desire for, or takes any overt action toward shortening
their life must be afflicted with a mental illness” (Rich, 2014, p. 403). Researchers
who ascribe to this view have argued that approximately 90 percent of people who
kill themselves met the criteria for a mental disorder at the time of their death
(Arsenault-Lapierre, Kim, & Turecki, 2004), although others place the rates at closer
to 30 percent (Milner, Sveticic, & De Leo, 2012; Owens, Booth, Briscoe, Lawrence,
& Lloyd, 2003). Whatever the true rates might be, however, the presence or absence
of a mental illness says nothing practically useful about whether a client will kill
themselves or not. Most people with a mental illness do not take their own lives and
many people who do so are not mentally ill.
Even the fact that suicidality is a manifestation of mental illness for some people
does not justify trying to stop them from killing themselves, however, because not
every product of mental illness is considered worthy of prevention. The urge of many
who produce great works of art, for example, is a manifestation of mental illness, and
that does not warrant stopping them from trying. Even the desire to recover from
mental illness could be said to be a by-product of the illness, but surely no one would
suggest that we are obligated to prevent someone from getting better. So even if all
suicidal intent were the product of mental illness (which is certainly not the case), it
is not sufficient reason for preventing someone from acting on it. Indeed, the courts
have ruled that the only time they would relieve someone with a mental illness of
their responsibility for suicide was if they are incapable of voluntary behavior
(Appelbaum, 2000).
In some situations, people suffer from a mental disorder that restricts their ability
to make a rational decision about whether to live or die, as in the case of command

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 142 Ethical Issues in Specific Settings

hallucinations or psychotic depression. In these situations, suicide is not a voluntary

choice of death over life and we are therefore expected on compassionate grounds to
intervene against the client’s wishes in order to promote their welfare. In other
situations, people want to end their lives because they suffer under a mental disorder
that leaves them feeling demoralized by their inability to overcome it. In these
situations, suicide is an autonomous choice and coercive treatment is therefore
ethically contraindicated.
Even proponents of risk assessment concede that it has no predictive utility and
argue instead that it serves to guide treatment planning (Bryan & Rudd, 2006).
The final practical nail in the coffin of suicide risk assessment, however, is that it
does not have the necessary discriminating power to distinguish groups of patients at
higher and lower risk of suicide in a way that provides a useful guide to treatment.
Any therapeutic intervention delivered to those who are categorized as high-risk for
suicide can only decrease the likelihood of suicide and not eliminate all risk, and the
vast majority of those labeled high-risk would never have killed themselves.
Furthermore, given that most suicides occur among people categorized as low-
risk, and who are 14 times more likely to take their own life than those in the general
population (Steeg et al., 2012), any intervention with a chance of success should
surely be applied to low-risk clients as well. Also, assessing the level of a client’s risk
tells us nothing about how best to respond to their suicidality. Thus, we are left with
having to take seriously all clients who express suicidal ideation or intention and
applying our energies to addressing their suffering.
Practicalities aside, legal liability has been found for failing to recognize that
a client is suicidal and subsequently failing to address the aspects of the client’s
circumstances that are contributing to their suicidality. If our client is expressing
suicidal ideation or intent or we are otherwise worried that a client is suicidal,
however, an assessment does nothing to protect us from liability for failing to detect
suicide risk because we are already aware of it. Our responsibility is to do something
about whatever is motivating our client to want to end their life.
The therapeutic situation with clients who are persistently suicidal, in contrast
with clients who are experiencing acute suicidality, highlights how an excessive
focus on the illusory goal of preventing a suicide by assessing risk actually interferes
with us meeting our ethical obligations. When our goal is to do whatever it takes to
prevent a client from killing themselves, we are placing the promotion of their well-
being, as we understand it, ahead of respecting their autonomy. Indeed, we are now in
a position of trying to outguess the client’s true intentions while they are forced to try
to outwit us in order to achieve their goal. In such circumstances, we often resort to
labeling a client as “manipulative” who is simply trying to further their own interests
as they understand them.
Suicidal ideation, intent, and attempt, like any other symptoms, are clinical
phenomena that we are expected to address therapeutically. Treating chronically
suicidal patients as if they were always in danger reinforces cycles of repeated,
exceptional interventions that hinder good therapy. People contemplate or attempt
suicide when it seems like their best, and sometimes only, way out of an unbearably
difficult situation in which the challenges that confront them overwhelm whatever

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 Working with Clients Who Are Persistently Suicidal 143

resources they have to deal with them. Often their resources are depleted, perhaps
because the people who usually support them have abandoned them or because their
ability to generate a nonfatal solution is impaired by mental illness or intoxication.
Always somewhere prominent in the mix of the fatal act is excruciating psycholo-
gical pain.
By persistently conducting suicide risk assessments with the persistently suicidal
Caroline, I took precious time away from responding to her psychological pain.
In fact, by making the assessment of her risk the priority in our professional contact,
the focus of our therapy shifted from her goals to mine. Ultimately, I was expected to
help Caroline deal with her real-life issues, not to protect myself from legal liability.
By spending so much time worrying about suicide, the process of good therapy
became derailed. From the outset, I should have focused less on responding to her
threat of suicide and more on working collaboratively with her to resolve the distress
that gave rise to it.

Providing Care versus Respecting Autonomy

Delia presented for psychotherapy stating that she wanted to talk with
a therapist to ensure that she “left no stone unturned” before taking her own life.
She described her days as “endlessly sad” and couldn’t remember ever being happy.
She had long ago given up trying to find any reason for living in the face of her
“unbearable sadness” and thought about suicide almost constantly. In particular, at
night in her apartment she often felt oppressively miserable, which prompted her to
actively consider how she might end her life. She said that at those moments the
prospect of a life of such pain, stretching out interminably, was more than she could
stand. What had prevented her from killing herself was that she did not want anyone
to have to deal with her corpse: “I can’t imagine how awful it would be for someone
to come into my apartment and find my dead body. That would be horrible.”
By this point in my career, I had considerable experience with suicide and felt up
to the task of helping Delia. I agreed to work with her on the condition that she not
kill herself until we had exhausted all therapeutic possibilities. This was not actually
too difficult – she was prepared to collaborate with me so long as I was not
categorically opposed to her taking her own life. I told her I was not convinced
that suicide was the solution to her suffering, but would keep an open mind.
In truth, I felt confident that I could establish a therapeutic alliance strong enough
to prevail over her deeply demoralized state. I knew that if I explicitly opposed her
wish to die, she wouldn’t feel we were collaborating toward a shared goal. But I did
not accept that her life was not worth living. The fact that she sought my help and was
worried about the effect of her suicide on people she did not even know led me to
believe that she was capable of meaningful, satisfying relationships.
The tenuous state of our alliance was tested frequently, however. Delia would call
at night feeling desperately sad with an overwhelming urge to die. Many times
I intervened to prevent her from killing herself, choosing my words carefully in order
to maintain some semblance of working together. More than once I accompanied her

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 144 Ethical Issues in Specific Settings

to the emergency ward when she was intent on suicide and ambivalent at best about
adhering to our safety plan. Twice she was admitted involuntarily after I, without
telling Delia, argued with the attending physician that she posed a significant threat
to her own life as a result of a mental illness.
After six months of therapy, our work together took a sharp turn. Delia told me that
she had been diagnosed with terminal cancer that had started in her breast and
metastasized to her bones and internal organs. There was no possibility of cure.
She wanted to continue our sessions and within a few short weeks I was providing
bedside therapy in her apartment. A nurse visited daily to check on her, but she was
otherwise on her own. She told me that the certainty of her death did have an upside:
it freed her from having to agonize over whether to go on living. Yet while her
physical pain was being kept under control for the time being, it would soon outpace
the medication options available. She was very much afraid of the suffering she
would have to endure as the end of her life neared.
Then one day Delia asked – pleaded, in fact – to “help me end my life now, on my
own terms, before dying an ugly, painful death.” I was stunned. When she was
dealing with intractable emotional pain, I never lost hope that she would overcome it.
I even went against her wishes to keep that possibility alive. Now she faced
excruciating physical pain and I had nothing to cling to. I realized that my failure
to accept suicide as a reasonable choice was due to my unwillingness to accept that
we will all die eventually. Her inescapable death had broken through my denial.
I experienced a depth of compassion and sympathy for her that I had not felt before
and wanted to help.
The problem Delia – and I – faced was convincing the palliative care physician
specialist to help her hasten her death. The specialist was reluctant because of her
history of involuntary hospitalization for suicidality, for which I was more than
partially responsible. I now found myself arguing that she was competent to decide to
kill herself despite still being depressed. I said her desire to die was considered and
congruent with her personal values and her death would not negatively impact
significant others because she had none. Her physician relented and issued
a treatment order for enough pain medication to kill her. Delia died alone a few
days later by her own hand.
In response to his own rhetorical question, “Is life so dear or peace so sweet as to
be purchased at the price of chains and slavery?” during a rousing speech delivered to
the Virginia Convention on May 23, 1775, Patrick Henry famously answered,
“I know not what course others may take; but as for me, give me liberty, or give
me death!” Although few would take quite so vehement a stance, autonomy is
considered by most to be an essential and inviolable right worth dying for. Yet
when it comes to suicide – arguably the ultimate expression of autonomy – the only
means by which it can be prevented is to curtail personal liberty. This presents us
with a dilemma.
Historical trends show that considering personal autonomy as a basic human right
is a relatively new concept. Throughout much of recorded history, for example, many
people believed they were owned by or belonged to a god, and it was sometimes said
that our bodies were “on loan” to us from them. Similarly, many peoples have

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 Working with Clients Who Are Persistently Suicidal 145

believed that individuals were owned by their sovereign ruler, king, queen, chief,
emperor, or some other. These leaders were entitled to exert ownership under certain
circumstances, particularly when human resources were needed, such as the practice
of conscription during times of war. And until quite recently, on an historical scale,
many members of society, such as slaves, serfs, women, and children, were con-
sidered the property of another and could not assert that they owned their own
bodies. In fact, if we consider the global population, this is still true for significant
numbers of people.
The current consensus among the peoples of democratic countries, as reflected in
their laws, is that an individual cannot be said to be truly free who does not have
dominion over his or her own life. The view is that all persons own themselves. Our
mind and body are not collective resources; they are us and they are ours. In a free
society, no one is owned by family, society, or country, or by any other individual.
We might therefore well ask why exercising power over individuals who want to
end their own life could be considered justifiable at all. There are many situations
where we allow people to engage in activities that can reasonably be expected to
result in self-harm. Obvious examples include contact sports such as football and ice
hockey. It is very difficult to imagine anyone being forcibly prevented from partici-
pating in such sports on the basis that they might seriously injure themselves. In these
situations, the individual is clearly considered to have the freedom to subject their
body to risk of harm.
Then there are those activities where the chance of serious physical injury, if not
death, exists as a very real possibility. Any mistake or error in judgment when
engaging in “extreme sports” such as mountaineering, motor racing, and BASE
jumping, for example, carries mortal risk by its very nature. Yet as with the relatively
milder contact sports, the autonomy of persons engaging in these life-threatening
activities is not restricted even though the outcome can be, and often is, their death.
There are also behaviors well-known to hasten a person’s death, such as smoking
tobacco, consuming excessive amounts of alcoholic beverages, and avoiding physi-
cal activity. Despite the entreaties of experts to change our collective unhealthy
lifestyle, there does not appear to be any movement toward considering the many
self-inflicted deaths resulting from them as suicides. We may introduce “sin” taxes
and other methods to make engaging in such behaviors more difficult or to nudge
people toward healthier behaviors, but no one is seriously suggesting taking away
peoples’ liberty to shorten their own lives in this manner.
Current mental health policy and practices with respect to people who are suicidal
are thus curiously inconsistent with recognition of self-ownership in other spheres of
life. The modal position is that suicide ought to be prevented in most, if not all, cases
regardless of the wishes of the suicidal person. Authority to usurp personal autonomy
when individuals represent harm to themselves is even enshrined in the mental health
laws of numerous countries (O’Brien, McKenna, & Kydd, 2009; Sheehan, 2009).
Of course, the crucial difference between those who risk their lives through
dangerous activities or hasten their death through unhealthy lifestyles and those
who want to end their lives is intention. High-risk sports have as their goal enjoy-
ment. Participants often say that they feel “more alive” when they risk their necks.

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 146 Ethical Issues in Specific Settings

Similarly, smoking, drinking, and loafing on the couch is done for the pleasure of the
activity. Death or a shorter life is an unintended consequence. What troubles us so
deeply about suicide is that death is not a possible outcome of an activity, it is the
goal.
The ethical challenge for most psychologists with respect to a client who is
persistently suicidal arises out of our usual desire to work in collaboration with our
clients toward the goal of improving their well-being. When faced with a client
whose intentions and behavior are, from our perspective, contrary to their welfare,
our ethical obligation to provide responsible caring becomes incompatible with our
ethical obligation to respect their autonomy. Moreover, the client’s persistent suici-
dal intent calls into question the underlying values of our profession to promote life,
well-functioning, bodily integrity, and psychological health. Few of us find such
questioning a pleasant experience.
In fact, clients who are persistently suicidal frighten us. Fear of legal sanctions is
of course quite common and, on the face of it, understandable given that no one
wants to be sued or disciplined. But we are accountable for many actions that could
result in a lawsuit or complaint, such as crossing professional boundaries or failing to
properly diagnose, and few of us live in fear of these events to anywhere near the
extent we do of suicide. Our fears when dealing with someone intent on killing
themselves go deeper; they are primal.
All living things are born with biological systems oriented toward self-
preservation. Those who lack it would be at a distinct reproductive disadvantage
relative to those who would do anything to stay alive. Yet human beings are, as far as
anyone knows, unique among all forms of life in being aware of our mortality
(Solomon, Greenberg, & Pyszczynski, 2015). We know that sooner or later we
will lose the battle against death. In fact, humans are so terrified of death that we
go to great lengths in thought and deed to deny it (Becker, 1973). When circum-
stances conspire to overwhelm our denial and make our mortality salient, death
anxiety is aroused and we seek to defend ourselves against it by clinging more tightly
to our core beliefs about the nature of the world and our place in it (Pyszczynski,
Solomon, & Greenberg, 2015). Working with a client who desires to end their own
life is an obvious threat to our denial of death and may arouse awareness of our own
mortality.
Belief in the sanctity of life is so fundamental to our worldview that few of us
ever stop to even consider its centrality. Beliefs of this kind typically arise
without conscious effort such that we rarely question their presence in our
minds any more than we question whether something has a particular shape,
texture, or taste. That is, we trust our fundamental assumptions as much as we
do our perceptions. The feeling that we should intervene to save someone from
dying, therefore, is usually experienced as a fact that we should do so. That
dying should be their intention only serves to make it less comprehensible and
more worthy of prevention (Liégeois & Eneman, 2012). The net result of this
process is that we are at risk of trying to intervene with suicide in ways that
seems obviously to be the correct thing to do, yet are inconsistent with society’s
expectations of us and our professional codes of ethics.

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 Working with Clients Who Are Persistently Suicidal 147

Our human capacity to be aware of our mortality not only provokes existential
fear, it also presents us with the choice of whether to live or die. And if the choice
exists, there must be some situations where choosing to die is a reasonable alter-
native. It is illogical to declare people unable to reason logically simply because they
consider suicide. Autonomous individuals have the right to behave in any noncrim-
inal way they choose. If suicide can be logically considered, then we are expected to
grant mature individuals who are capable of deciding whether to live or die the
autonomy to understand their situation from their personal framework.
In fact, most democratic societies have accepted that choosing to hasten one’s
death can be rational under certain circumstances. Over the last decade, a number of
prominent professional organizations have issued policy statements or position
papers asserting that the provision of a lethal prescription requested by
a terminally ill patient who is competent to decide is just and ethical. This trend
reflects a shift in societal attitudes away from the view expressed by the U.S.
Supreme Court in the cases of Washington v. Glucksberg (1997) and Vacco v. Quill
(1997) that use of a lethal prescription by a terminally ill patient constitutes suicide,
and toward the position taken in the case of Compassion in Dying v. Washington
(1995) that such action can be the exercise of autonomy in determining the time and
manner of one’s death.
It is now accepted in most democratic countries (including Canada and the United
States) that a person has the right to hasten his or her death following a sound
decision-making process when faced with the intolerable suffering associated with
a terminal illness (Werth & Holdwick, 2000). Death can be the result of withholding
or withdrawing life-supportive technologies or procedures, as well as providing
a person with the means to die (usually medication) and having them self-
administer it.
Thus, when someone has a high likelihood of severe suffering, as in cases of
terminal illness, their decision to die seems understandable. Even if we find it
difficult to endorse an individual’s death wish, it is comprehensible because they
are going to die soon and their remaining quality of life will be poor. Death in this
instance is seen as a relief from dying.
This line of reasoning assumes a particular definition of the concept of “quality of
life,” however. The death wish is acceptable to us because we accept the objective
constraints due to a terminal illness as a valid reason. Yet, if we define quality of life
objectively, we have to ask why we do not find the lack of suicidal intent incompre-
hensible among those facing a horrible death. Indeed, we tend to consider such
stoicism to be admirable. If, on the other hand, quality of life is subjectively defined,
it follows that most death wishes must be acceptable, because for a suicidal person
their life is unbearable by definition. But we certainly do not consider subjectively
experienced suffering as sufficient to make suicide acceptable in every case.
Our inconsistency is the product of the tendency to ask ourselves whether we
would feel similarly in the same situation and make the same decision. If someone
who is suicidal does not feel or decide as we think we would, then we tend to rely on
the implicit norms of our worldview to judge which constraints count as bearable and
which do not. We do accept that some people can endure more suffering than most,

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 148 Ethical Issues in Specific Settings

and indeed venerate them because we hope that we would do likewise if faced with
the same challenge. Yet we tend to consider it incomprehensible if someone wants to
kill themselves to escape circumstances that we consider tolerable, and typically
judge them negatively for showing a weakness of character that we fear we would
manifest if similarly tested. If we do not understand or, worse, do not approve, then
we do not accept their justification for wanting to die. And our understanding and
approval are very much dependent on our comfort with and acceptance of our own
mortality (Arndt, Vess Cox, Goldenberg, & Lagle, 2009).
It should be clear, therefore, that we ought neither to judge the validity of an
individual’s distress by an objective standard nor to make the acceptability of
suicide dependent upon imagining ourselves in our client’s situation. The fact
that suicide can be reasonable, even rational, for some people in some circum-
stances requires us to accept that an absolute position against suicide is not
a tenable one. How, then, do we proceed with the knowledge that there is no
ultimate perspective on suicide to which every other viewpoint is subservient?
How do we move forward when our fundamental belief that continuing to live
under any circumstance is flawed?
My ability to effectively navigate the expectations of our professional ethics and
laws when working with Delia in her persistently suicidal state was hampered by my
inability to manage my fear of death. If I had a better handle on my existential terror
from the outset of our work together, then I could have better met her on her own
terms. She was faced with a life that, by her own assessment, was intolerable.
My role was not to contradict her about the rightness or wrongness of suicide as
a way of ending her suffering. Doing so put me in opposition to her goals when I had
no right to do so. I did have an obligation to help her find a way to overcome or find
peace with her sad and lonely life. I should have collaborated with her to resolve the
despair that was driving her to consider suicide. It may have turned out that, despite
my best efforts, her appraisal of her life would have remained unchanged and she
may have decided to end it. But interfering with Delia’s autonomy to decide whether
or not to continue living was an affront to her dignity as a person and, rather than
saving her life, only served to diminish it.

Recommendations for Responsible Practice

The overarching ethical issue with respect to suicide is whether, or under
what circumstances, we should attempt to prevent it by interfering with an indivi-
dual’s autonomy. As a society, we allow people to act in many other noncriminal
ways that are not in their best interests and that even put their life in serious jeopardy.
Yet we treat suicide differently. Most of us consider it intrinsically wrong or at least
the wrong thing to do under most if not all circumstances. Although it is not logically
persuasive to seek to prevent a suicide only because we cannot understand the
individual’s wish to die – or to allow it because we understand and agree with their
intent – our decision to coercively intervene in practice typically does hinge on this
very ability.

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 Working with Clients Who Are Persistently Suicidal 149

The greatest barrier for most of us to responding in an ethical manner to the

possibility of suicide is that it strikes at the heart of our existential fear of death.
Acknowledging that suicide arouses this fear and that our actions may be motivated
as much by protecting ourselves from existential anxiety as by protecting our client is
a necessary and, for most of us, a very difficult step. We are expected to keep an open
mind that suicide can be a rational choice when faced with an unbearable life
situation in at least some cases and to respond to each client as an individual facing
unique circumstances.
Assessing suicide risk with a client who we know to be suicidal may be an
example of our unacknowledged fear of mortality given that it serves no purpose
other than to calm our anxiety. While legal liability can be imposed for failing to
detect suicide risk, by definition if we are worried about our client’s suicidality we
have already detected it. Assigning a degree of suicide risk to a suicidal client thus
has no legal benefit, and nor does it provide any predictive utility or treatment
guidance. Our time and energies are better spent addressing whatever psychological
issues are contributing to our client’s wish to die.
For many clients presenting with suicidal concerns, the desire to end their life
is strongly influenced by a mental illness and may, as a result, be less voluntary
or deliberate than those not so afflicted. A mental disorder can result in
a diminished capacity to make a rational choice to end one’s life, but certainly
not completely and not in all instances. Much more typical is that a client
suffering from a mental illness loses perspective on their situation and struggles
to make a decision one way or another. Under such circumstances, suicide can
seem to be the only way to escape the intolerable situation of not knowing how
to resolve the overwhelming burden of one’s life. Many clients also feel demor-
alized and desperate as a result of suffering from a mental disorder while
retaining the capacity to make a voluntary and deliberate choice of suicide.
In such situations, a person can take stock of their life and come to an inten-
tional and thoughtful decision that it is not worth living.
Of course, the client who is unambivalently intent on dying, rare as they are, will
find a way to kill him/herself, no matter how hard we try to prevent it. A reasoned
choice to end one’s life remains an individual’s prerogative, however, and only
through laborious coercive intervention are we able to orchestrate brief delays.
We do so in the hope that time and further treatment might reduce the client’s risk
of suicide through the ameliorating of a mental illness, strengthening the therapeutic
relationship, or inculcating a more positive appraisal of their life and its value. If we
cannot realistically anticipate that the client’s wish to die will diminish via our
intervention within a reasonable period of time, or if in fact it does not do so after
a period of treatment even though we expected it to, our ethical position becomes
progressively more tenuous. Thus, a coercive intervention that is defensible in many
situations of acute suicidality becomes increasingly problematic and unjustified as an
obligation to provide care when a client demonstrates a wish to die over an extended
period of time or treatment. If we assume perpetual responsibility for protecting
a client from their suicidal wishes, we are no longer simply providing treatment, but
instead are infantilizing and dehumanizing them.

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 150 Ethical Issues in Specific Settings

When working with a client who is persistently suicidal, we are expected to seek
to collaborate with them and to find a consensus on goals that we can both agree to
work toward. As paradoxical as it may seem, the prevention of suicide is not always
furthered by coercive rescuing. The approach that has the best chance of dissuading
someone struggling with suicidality begins with empathy because it forms the basis
of hope and facilitates problem-solving. Communicating our understanding of just
how desperate and hopeless our client feels constitutes a profound intervention by
offering the experience of being appreciated rather than coerced. Basing our work
together on empathy avoids the trap of having the client view therapy as an
oppressive force pressuring them to continue living what they experience as an
unbearable life or arguing that their life is worthwhile. Such a domineering stance
is very likely to be ineffective and is often actually countertherapeutic. Rather,
providing a human encounter that allows us to consider together the struggle and
burdens involved in living can in itself decrease the tendency toward compulsive
expression of suicidal desires. Empathic understanding allows a chronically sui-
cidal client the freedom to consider whether their expressed intentions are truly
a choice to die or, as is very common, an act of desperate defiance in response to
overwhelming psychological pain, insoluble personal troubles, and pressure to
continue living.
Working with clients who are persistently suicidal requires us to negotiate
a delicate balance between respecting autonomy and providing care. People consider
their lives worth living only if they enjoy an adequate degree of autonomy to live as
they see fit. As psychologists, we are expected to respect our clients’ autonomy
because it is accepted in our society as a fundamental human right and it is
a necessary condition for wanting to live. Thus, we are expected to grant our clients
as much autonomy as possible, which in practical terms means restricting their
autonomy as little as possible. On the other hand, we are also expected to assume
responsibility for providing effective psychological care, including limiting our
clients’ autonomy when necessary, if their risk of suicide is a product of an invo-
luntarily, irrational decision-making process. However, we must be careful to avoid
the mistake of considering someone presenting with mental health concerns to be
irrational until proven otherwise. All in all, this represents a very difficult practice
situation, but hopefully one in which the relevant parameters are now more clearly
articulated.

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