Working with Suicidal Clients

Michael Griffin, JD, LCSW,
Staff Attorney 
The Therapist
March/April 2022

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It’s understandable that a therapist would experience some degree of trepidation when working with a suicidal client. Therapists have a profound responsibility when treating someone who is in such extraordinary pain. But the responsibility is inescapable: Statistically, every clinician is likely to encounter a suicidal client at some time in his or her career.¹ As a result, every therapist should be concerned about what the law expects of him or her when working with such a client.

This article discusses key legal issues that are generally applicable when treating a suicidal client. It also briefly discusses the topic of assessing and managing risk when working with suicidal clients. The CAMFT website contains various resources related to the topic of suicide, including a collection of training videos entitled “Suicide Prevention Package” available in the On Demand Learning Library. As of January 1, 2021, existing licensees and applicants for licensure must have completed a minimum of six hours of coursework or applied experience under supervision in suicide risk management and intervention.

Key Legal Issues
When a therapist is aware that their client is at risk of completing suicide, courts have generally held that they have a duty to take “reasonable” or “appropriate” steps to prevent the client’s suicide.² However, the definition of what may be considered “reasonable” depends on the facts and circumstances of the case. There is not a list of actions or interventions that can be applied uniformly to all suicidal clients in all circumstances.³

The case Bellah v. Greenson provides an example of what is generally expected of a therapist whenworking with a suicidal client.⁴ In this case, the parents of an adolescent girl who died by suicide brought a lawsuit against their daughter’s former psychiatrist wherein they alleged that he was negligentbecause he failed to provide reasonable care to prevent her suicide. The parents also contended that Dr. Greenson was negligent because he failed to inform them that she was engaging in high-risk behavior during the time that she was in treatment.^{5 6} In its decision, the Court of Appeals agreed that Dr. Greenson had a duty to exercise reasonable care in his treatment of the girl, meaning that he was expected to take “appropriate preventive measures” concerning her risk of suicide.⁷ But the court did not agree with the plaintiffs’ contention that Dr. Greenson had a specific duty to disclose his client’s confidential information to her parents.⁸

What did the court mean when it used the words “appropriate preventive measures”? And why did the court disagree with the plaintiffs argument that Dr. Greenson was negligent because he didn’t tell them about their daughter’s high-risk behavior? To answer such questions, it may be helpful to briefly review the primary legal issues at the heart of a negligence (malpractice) lawsuit against a mental health professional.^{9 10}

The Elements of Negligence
When a therapist is sued for negligence, the plaintiff must prove by a preponderance of the evidence that^:11 the therapist owed a duty of care to the patient, the therapist breached their duty by failing to meet the standard of care expected under the circumstances, and the therapist’s conduct actually and proximately caused the plaintiff to be harmed.¹² “Actual causation” means that “but for” the actions of the therapist, the plaintiff would not have been harmed. “Proximate causation” means that the alleged harm to the plaintiff was foreseeable to the therapist as a possible consequence of their actions.¹³

The Duty of Care
Courts have long recognized that a psychotherapist owes a duty of care to their clients.^{14 15} Thus, if a client-therapist relationship existed at the time of the alleged wrongdoing, there was a duty of care owed to the client. Generally speaking, the duty of care is based upon the existence of a “special relationship” between the therapist and their client.^{16 17}

The Standard of Care¹⁸ 
The applicable standard of care depends on the facts and circumstances present in the case. To determine the appropriate standard of care, the court will usually require the opinions of relevant experts. The expert(s) will provide their opinion as to what is expected of a therapist who is exercising the reasonable degree of skill, knowledge, and care ordinarily exercised by other therapists practicing under similar circumstances.¹⁹

In terms of the applicable standard of care in Bellah v. Greenson, although the adolescent client was at risk for suicide during treatment, the court was not inclined to rule that Dr. Greenson was required to disclose her confidential information to her parents. It wasn’t that the court lacked compassion for the terrible loss that her parents had suffered.

The court recognized that if every therapist was faced with a broad mandate to disclose confidential information regardless of whether it was clinically appropriate to do so, the disclosure itself could result in the rupture of the therapist-client relationship and potentially increase the client’s risk of suicide. Furthermore, the existence of such a rule would be at odds with the fundamental privacy of the therapistpatient relationship. On this issue, the appeals court also rejected the plaintiffs’ contention that the landmark case Tarasoff v. Regents of University of California created a “duty to warn” under the circumstances found in Bellah v. Greenson, writing,

We disagree with plaintiffs in their contention that Tarasoff v. Regents of University of California created a duty on the part of the defendant in this instance to breach the confidence of a doctor-patient relationship by revealing to them disclosures made by their daughter about conditions which might cause her to commit suicide. In Tarasoff, the California Supreme Court held that, under certain circumstances, a therapist had a duty to warn others that a patient under the therapist’s care was likely to cause personal injury to a third party … The imposition of a duty upon a psychiatrist to disclose to others vague or even specific manifestations of suicidal tendencies on the part of the patient who is being treated in an out-patient setting could well inhibit psychiatric treatment.²⁰

Actual and Proximate Causation: Was the Alleged Harm Foreseeable to the Therapist?²¹
As stated above, in a negligence lawsuit it must be shown that the harm in question was foreseeable to the therapist as a possible consequence of their actions. A therapist cannot be expected to implement preventive measures in a case where the potential suicide of their client was not reasonably foreseeable. Thus, in a case involving the alleged negligent failure of a therapist to prevent their patient’s suicide, one of the fundamental issues is whether or not the therapist was aware of facts from which they could reasonably conclude that the client was likely to self-inflict harm in the absence of preventative measures.²²

It is important to remember that the client information available to a therapist is related to the time, energy, and skill they invest in collecting it. In other words, did the therapist assess their client in accord with the relevant standard of care? A therapist may not be aware of facts from which they could reasonably conclude that their client was at risk of self-harm if they failed to exercise the reasonable degree of skill, knowledge, and care that would ordinarily be exercised by other therapists when conducting an assessment of a client^.23 Ultimately, whether the therapist was reasonably competent in conducting an assessment of their client depends on the facts and circumstances involved.

No list of questions is appropriate for all clients. One client may be relatively forthcoming when asked about their ideation. Another client may minimize their history of depression but have a record of psychiatric hospitalization that could prove enlightening to the therapist if they request the documentation. Alternatively, a consultation with a client’s psychiatrist may provide the therapist (and the psychiatrist) with valuable diagnostic information.

Identifying and Responding to Risk Factors for Suicide
There are numerous articles in the literature that discuss the topic of risk management in clinical practice with suicidal clients.²⁴ In this context, the term “risk management” refers to a therapist’s efforts to identify the risk factors for suicide that may be present and to prevent the client from self-harming.²⁵ Such efforts may include but are not limited to: facilitating the client’s hospitalization, consulting with their psychiatrist, increasing the intensity of the client’s treatment, asking the client to sign a no-self-harm agreement, attempting to increase the degree of social support available to the client, and involving a family member or friend in the treatment plan, etc. However, no therapist can predict with certainty what their client will do or control the client’s actions. The preventive measures a therapist employs depend on the needs of the client, the surrounding circumstances, and the information available about the client.

A therapist is not legally required to be correct in their assessment of a client’s risk for suicide. Therapists are no better at predicting the future than anyone else. Thus, the fact that a suicide occurs does not in itself prove there was a breach in the standard of care.²⁶ There is an expectation, however, that the therapist will take reasonable steps to obtain information about the client that helps determine the risk of suicide.²⁷

No two clinicians are alike, and every therapist will employ their own style or approach to gathering information about a client (e.g., taking a psychosocial history), assessing the client, and arriving at a diagnosis and treatment plan. When the therapist suspects there is a suicide risk, they should ask the client directly whether they are experiencing any suicidal ideation and, if so, to describe it. It is important to inquire about any history of treatment and problems with depression, including any prior suicidal ideation or attempts. When the client has been treated previously in an inpatient setting, it is also a good idea to seek authorization from the client to request a copy of their treatment records. If the client was recently treated in an inpatient setting and/or they are admitted to an inpatient program based on a severe risk of suicide, the therapist should make reasonable and appropriate efforts to communicate with the relevant inpatient staff, including the attending psychiatrist, if possible.²⁸ And of course, in cases where there is a risk of suicide it’s advisable for the therapist to consistently and thoroughly document their treatment efforts and corresponding clinical rationale, along with the degree of the client’s cooperation with any recommendations given.

The treatment plan or specific intervention that is best suited to a given client is a function of that client’s needs and the surrounding circumstances, including any resources available to the therapist at that time.²⁹ As an example, the therapist may believe that a partial hospitalization program is ideal for a client. But if there is no such program in the community where the client resides, or if the available program is filled, then the therapist must consider the next-best choice(s) for that person and create a plan based on the existing treatment alternatives. So the client who would be well served by the therapeutic intensity and support offered in an all-day treatment program may not have such an option available to them and will need to consider an alternative plan, such as meeting with their therapist more frequently along with the ongoing collaboration of a psychiatrist. But as every practicing therapist knows, if “Plan B” isn’t an option then it’s necessary to move on to the next available treatment options, and so on. This is why a therapist can only be expected to do what is reasonable under the circumstances.

There is a large body of information available to therapists on the topic of identifying risk factors for suicide,³⁰ and there’s a fair amount of information available regarding the range of actions that a therapist should consider in this area^.31 Actions that may be appropriate in some circumstances with some clients may not be unnecessary or appropriate in others. A therapist should strive to implement a course of action that they consider reasonable and appropriate for their client at that time. Some of the key factors that a clinician may consider when assessing their patient’s suicide risk include but are not limited to the following:³²

1. When there is a severe risk of suicide, it is necessary to consider the need for hospitalization to stabilize the client’s symptoms and to protect the client.
2. When evaluating a client, it is important to consider any preexisting risk of suicide, including the client’s history of depression and suicidal behavior. Previous suicide attempts are associated with an increased risk of suicide, especially when there is a history of two or more attempts.
3. There is evidence that clients face an elevated risk of suicide during the first year following an admission for inpatient psychiatric treatment, especially during the first few months after discharge.
4. Depending on the diagnosis, there may be a need to refer the client for psychiatric evaluation. When a referral is indicated, the therapist should make a reasonable effort to consult and collaborate with the psychiatrist regarding the client’s treatment.
5. The presence of a major mood disorder is a significant risk factor for suicide. Borderline personality disorder and antisocial personality disorder are also associated with an increased risk of suicide.
6. Numerous studies have reported that a client’s experience of hopelessness is a substantial risk factor for suicide.
7. A history of alcohol or drug abuse is associated with an increased risk of suicide.
8. A history of impulsive behavior is associated with an increased risk of suicide.
9. The availability of a support system for the client is a key consideration in suicide risk assessment and treatment planning.

The Use of No-Suicide Contracts
It’s common practice in both inpatient and outpatient settings for clinicians working with high-risk clients to use no-suicide contracts.³³ The phrase “no-suicide contract” is somewhat inapt, as this device is intended to serve as a therapeutic tool rather than an enforceable legal contract. Also referred to as a “no-selfharm agreement,” a no-suicide contract is an agreement between the clinician and their client wherein the client agrees to avoid selfharm and to seek help from the therapist or other identified person when they experience suicidal urges.³⁴

Despite their prevalence, there is little empirical evidence that no-suicide contracts are effective in preventing suicide in the absence of other treatment efforts.35 Various criticisms have been levied against their use, including:

1. The no-suicide contract may create an illusion of safety.
2. The refusal of the client to agree to a nosuicide contract does not necessarily mean that they are at imminent risk of suicide.
3. The willingness of the client to agree to a no-suicide contract does not necessarily mean that the risk of suicide has lessened.
4. The presence of psychiatric symptoms, such as severe depression or psychosis, may impede the client’s mental capacity to enter into such an agreement.
5. The client may be willing to sign such an agreement simply to placate the therapist.
6. The therapist is asking the client to enter into an agreement with life-and-death consequences even though they may have had little time to develop genuine rapport.
7. The client who feels amenable to the agreement at one moment may feel quite different after leaving the therapist’s office.

Therapists should never rely upon a nosuicide contract as a sufficient preventive measure by itself, and they should exercise their clinical judgment as to whether a nosuicide contract is of value in a particular case. Despite its shortcomings, a no-self-harm or no-suicide agreement may have some clinical utility as part of a therapeutic plan. When used cautiously depending on the client’s circumstances and needs, its possible benefits include:

1. It may help facilitate honest and direct communication between the therapist and their client.
2. It expresses an expectation that the client actively participate in their treatment.
3. It defines a process for handling emergencies.
4. It may alleviate some of the client’s anxiety by providing a structure to follow.

Communicating With Others: Relevant Exceptions to Confidentiality
When dealing with a client who is a danger to themselves, the therapist may determine that to provide appropriate treatment it would be helpful or even necessary to communicate with a third party. For example, the therapist may wish to speak to the client’s physician, family member, or spouse because they believe that it will yield critical information or that it’s necessary to prevent the client from harming themself. In another example, the therapist may determine that calling the police is an urgent necessity to prevent the client (or some other person) from being seriously harmed. In such circumstances, the therapist is permitted to disclose confidential information about their client, pursuant to the following sections of the California Civil Code:³⁵

Section 56.10(c)(1) of the Civil Code states, “The information may be disclosed to providers of health care, health care service plans, contractors, or other health care professionals or facilities for purposes of diagnosis or treatment of the patient…”³⁶ (This means that the therapist would be permitted to communicate with the client’s physician or another mental health care professional, to name just a few examples, without a release if such communication was for the purpose of diagnosing or treating the client.)³⁷

Section 56.10(c)(19) of the Civil Code states that a psychotherapist can disclose confidential information about the client “if the psychotherapist, in good faith, believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”38 39

The Bottom Line: Preparation is Key
Not all therapists want to work with a suicidal client or are competent to provide ongoing therapy to one. But in light of the frequency of suicide, especially among adolescents and young adults, it’s important for every therapist to have sufficient competency in the assessment of suicide risk so that they can exercise reasonable care under the circumstances to prevent the suicide from occurring. As stated earlier, it is reasonable for a therapist to experience some degree of trepidation about working with a client who is suicidal. If upon reflection a therapist finds that they are more than a little anxious, it may be appropriate to seek out additional training or to explore the possibility of consultation with a colleague who is well trained in assessing and treating suicidal clients. Finally, every therapist should take the time to become aware of the relevant treatment resources in their community, such as intensive treatment programs, as well as the psychiatrists available to evaluate a client or facilitate hospitalization if need be. It may also be helpful for a therapist to determine the other therapists in the area willing to accept the referral of a suicidal client, if necessary.

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Michael Griffin, JD, LCSW, is a staff attorney at CAMFT. Michael is available to answer member calls regarding legal, ethical, and licensure issues.

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References

¹ For example, in 2009, 13.8 percent% of U.S. high school students reported that they had seriously considered attempting suicide during the 12 months preceding the survey, and 6.3 percent of students reported that they had in fact attempted suicide one or more times during the same period. Among 15-to-24-year-olds, suicide accounts for 12.2 percent of all deaths annually. Centers for Disease Control and Prevention, “Suicide Facts at a Glance,” available on the Internet at http:://www.cdc. gov/violenceprevention/pdf/Suicide_DataSheet-a.pdf.

² Bellah v. Greenson, (1978) 81 Cal. App.3d 614; Jacoves v. United Merchandising Corp., (1992) 9 Cal. App.4th 88; Kockelman v. Segal, (1998) 61 Cal. App.4th 491; Gross v. Allen, (1994) 22 Cal. App.4th 354.

³ A therapist is not expected to be able to predict with certainty whether his client will attempt or complete suicide. This issue is further discussed in the section of this article entitled “Identifying and Responding to Risk Factors for Suicide.” Numerous publications address this issue, many of which are accessible via the EBSCO database, in the Psychology and Behavioral Sciences Collection. The EBSCO database is accessible to CAMFT members via the members-only section of the CAMFT website at www.camft.org. Use of the EBSCO database is a benefit of membership in CAMFT.

⁴ Bellah v. Greenson, Id.

⁵ Bellah v. Greenson, Id.

⁶ The parents’ argument was premised on their belief that they could have prevented their daughter’s death had they been informed that she was associating with heroin addicts during the time that she was in treatment.

⁷ Id.

⁸ Id.

⁹ See, Jacoves v. United Merchandising Corp; Kockelman v.Segal, Gross v. Allen, Supra.

¹⁰ A malpractice lawsuit against a health care provider is a lawsuit for negligence.

¹¹ The standard of proof in a negligence case is preponderance of the evidence. In other words, the evidence must reflect that it was more likely than not that the defendant was negligent.

¹² Black, H. C. (1990). Black’s Law Dictionary. St. Paul, MN: West.

¹³ Kionka, E. J. (1993). Torts. St. Paul, MN: West.

¹⁴ Bellah v. Greenson, Supra.

¹⁵ Although Bellah v. Greenson and similar cases concern the actions of a psychiatrist, the basic issues related to duty of care are generally applicable to other mental health professionals.

¹⁶ ee Also, Nally v. Grace Community Church, (1988) 47 Cal.3d 278 (no duty found where counseling was provided by pastoral counselors).

¹⁷ A legal duty is an obligation recognized by the law that requires a person to conform to certain standards of conduct. Black, H. C. (1990). Black’s Law Dictionary. St. Paul, MN: West.

¹⁸ n the law of negligence, the standard of care is the degree of care that a reasonably prudent person should exercise in same or similar circumstances. If a person’s conduct falls below such a standard, they may be liable for injuries or damages resulting from such conduct. In malpractice cases, a standard of care is applied to measure the competence of the professional. Generally speaking, a health care professional is expected to exercise the reasonable degree of skill, knowledge, and care that would ordinarily be exercised by other professionals in same or similar circumstances. Black, H. C. (1990). Black’s Law Dictionary. St. Paul, MN: West.

¹⁹ Jacoves v. United Merchandising Corp., Supra.

²⁰ Bellah v. Greenson, Supra., at 620-21.

²¹ The issues in a negligence case that concern causation will generally involve “proximate” causation rather than “actual” causation; proximate causation requires foreseeability of harm.

²² Jacoves v. United Merchandising Corp., Supra; Bellah v. Greenson, Supra.

²³ Id.

²⁴ I am referring to publications on the subject matter that may be found in professional journals, articles, and books. Much of the information used in this article was accessed via the EBSCO database (Psychology and Behavioral Sciences Collection), which is available to CAMFT members via the members-only section of the CAMFT website at www.camft.org.

²⁵ “Risk factors” are those facts from which the therapist could reasonably conclude that their client was at risk of harming themself in the absence of preventative measures.

²⁶ Berman, Alan L., “Risk Management with Suicidal Patients,” Journal of Clinical Psychology in Session, Vol. 62(2), 171-184 (2006) (Published online in Wiley InterScience).

²⁷ Id.

²⁸ ISee Also, Gross v. Allen, Id. (psychiatrist liable for failure to communicate patient’s high suicide risk to another psychiatrist who admitted patient to inpatient eating-disorder program, where she died by suicide).

²⁹ ISee Generally, Raue, Patrick J., PhD, Brown, Ellen L., Meyers, Barnett S., Schulberg, Herbert C., PhD, Bruce, Martha L., PhD, MPH, “Does every allusion to possible suicide require the same response?” The Journal of Family Practice, Vol. 55, No. 7, (July 2006); Overholser, James C., PhD, “2Clinical Care,” Frontiers of Psychiatry, Vol. 9, article 33, (Feb. 2018), www.frontiersin.org.

³⁰ Much of the information used in this article was obtained via the EBSCO database (which is accessible to CAMFT members as a benefit of membership) on the CAMFT website at www.camft.org. For example, see: “The Zero Suicide Model: Applying Evidence- Based Suicide Prevention Practices to Clinical Care,” Frontiers of Psychiatry, Vol. 9, article 33, (Feb. 2018), www.frontiersin.org.

³¹ See Generally, Bryan, Craig J., & Rudd, M. David, “Advances in the Assessment of Suicide Risk,” Journal of Clinical Psychology in Session, Vol. 62(2), 185-200, (2006) (Published online by Wiley InterScience); Packman, Wendy L., JD, PhD, Marlitt, Rebecca E., B.A., Bongar, Bruce, PhD, & O’Connor Pennuto, Tracy O., JD, MA,“A Comprehensive and Concise Assessment of Suicide Risk,” Supra.

³² Brian, Craig J., & Rudd, David M., “Advances in the Assessment of Suicide Risk,” Id.; Berman, Alan L., “Risk Management with Suicidal Patients,” Supra.

³³ Weiss, Andrea, M.D., “The No-Suicide Contract: Possibilities and Pitfalls,” American Journal of Psychotherapy, Vol. 55, No. 3, (2001); Rudd, David M., Mandrusiak, Michael, Joiner, Thomas E., Jr., “The Case Against No-Suicide Contracts: The Commitment to Treatment Statement as a Practical Alternative,” Journal of Clinical Psychology in Session, Vol. 62(2), 243-251, (2006) (Published online by Wiley InterScience).

³⁴ Id.

³⁵ Calif. Civil Code, section 56(c).

³⁶ d., section 56.10(c)(1).

³⁷ It is important to reiterate here that the facts and circumstances of a given situation are always critical factors in determining whether a particular exception to confidentiality applies. CAMFT members may call the CAMFT Legal Department for consultation as a benefit of membership.

³⁸ Calif. Civil Code, section 56.10(c)(19).

³⁹ California Evidence Code, section 1024, also provides that there is no psychotherapist-patient privilege in circumstances where the psychotherapist has reasonable cause to believe that the patient is in such mental or emotional condition as to be dangerous to himself or to the person or property of another and that disclosure of the communication is necessary to prevent the threatened danger.

This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.