Suicide

Prevention

Lab

Clinical Ethics and Risk Management: A Process Approach to Working with Suicidal Risk

David A. Jobes, Ph.D., ABPPProfessor of Psychology

Associate Director of Clinical TrainingDirector, Suicide Prevention Laboratory

The Catholic University of America

National Register of Health Service Psychologists2019 National Practice Conference

Washington, DC11/8/19

Disclosures

Funded by two NIMH grants; one AFSP grant

Book royalties (APA Press and The Guilford Press)

Founder and co-owner of CAMS-care, LLC (professional

training and consultation)

How do we think about ethics?

What are our considerations as clinicians?

Ethically Complex Cases

Just when you think you have seen it all, an odd, complex, unclear, and confounded case comes along leaving you stumped and not sure how to proceed…

With ethics there is almost always a way to “play it safe”—erring on the side of covering your own self interest (which may not always be in the patient’s best interest).

How do you feel about working in the “gray areas” of ethical decision-making?

Overview to our ethical codes… Historically there was some professional reluctance to developing ethics codes.

This attitude changed dramatically after WW II and the Nuremburg Trials.

Across disciplines our ethics codes have started very generally and become more and more specific with each revision.

Generally speaking, about 90% of ethical codes across mental health disciplines are essentially the same.

For example, consider the oldest of the mental health ethics codes, the APA ethics…

General (Aspirational) Principles

Beneficence and Nonmalfeasance

Fidelity and Responsibility

Integrity

Justice

Respect for People’s Rights and Dignity

Violation of Ethical Standards

Explicit acts that violate the specific ethical

guidelines of one’s profession (e.g, any of the

10 ethical standards of APA code).

Pillar #1:

Who is the Client?

A Different Ethical Question (Fisher, 2009)

“Who is the client?” is too narrow of a focus for a larger ethical sensibility.

Upon reflection, we have ethical obligations towards every party in a case, no matter how many.

This requires identifying all relationships and related ethical obligations.

The better question: “What are my ethical responsibilities to each of the parties in this case?”

Case Example:

The Knife Wielding Intoxicated Student

Jim was a 20-year-old alcoholic college student who was seen in the university counseling center for three sessions by a clinical psychologist for relational problems and depression. The psychologist is seeing a private practice client in his university office after hours when the session was interrupted by a campus security officer seeking out the psychologist because Jim is intoxicated and holding his RA hostage in his dorm room armed with a large hunting knife.

Pillar #2: Informed Consent

Informed consent is a major focus in the professional ethics and risk management…

Informed consent should be obtained as early as feasible.

Consent should be a continuing process.

The nature of psychotherapy should be fully disclosed.

The anticipated course of treatment should be shared.

Fees and financial arrangements should be fully discussed.

Informed consent continued… Involvement of any third parties should be made clear.

The limits of confidentiality should be understood by the client.

HIPAA and documentation considerations should be disclosed.

Consent for new and untested treatments.

Competency to give consent (minors/adults).

Cultural sensitivity should be assured.

Consent and trainee therapists.

Informed Consent Summary Sufficient information has been disclosed to make a fully informed decision

about treatment.

Participant was competent and consent was voluntary.

Risks and benefits were fully reviewed.

Put yourself in the patient’s place—what would you desire?

Case Example:

Informed Consent and Malpractice

A clinician was sued for malpractice (wrongful death) after a 12-

year-old boy that he met for five sessions hung himself in the

family garage. The plaintiffs complained that the psychotherapist

failed to appropriately assess, intervene, and provide adequate

treatment. At trial a brochure entitled “Welcome to My Practice”

that described the scope, limits, and various procedures of his

practice completely swayed the jury that the clinician had in fact

provided crucial information that was directly relevant to the

claims of the parents. The jury deliberated for a half hour and

found the clinician “not guilty” of malpractice.

Case Example:

A different kind of informed consent

A psychologist boards a plane on a trip to a military installation where he is providing clinical and research consultation. His seat mate on the plan is a friendly and engaging member of the US military. The seat mate engages the psychologist in casual conversation about work life, family, sports teams, etc. While the psychologist is intent on doing some work during the flight, the seat mate continues to engage in conversation. The flight attendant comes through the cabin and the seatmate offers to buy the psychologist a drink…

Structuring “Usual and Customary” Practices

Contacted for services—conduct an initial phone interview

Have initial face to face consultation (1 session)

Propose extended evaluation (4 sessions)

Propose 4 month of optimal treatment plan

Revisit treatment plan at the end of 4 months and continue

another 4 month proposed treatment plan

Work in 4 month intervals to ensure treatment is optimally effective

Clearly terminate but offer possible booster session consultations

Mental illness pre-enlightenment…

“Trephination”

“Moral Treatment” and the Asylum Movement…

Dr. Philippe Pinel ordering the release of

mentally ill from chains at Salpetrière an

asylum for women in Paris (1795)

A one-size mindset and hospitalization… Hospital suicides: 1800/year ( Knoll, 2012) vs. 49-65/year (The Joint Commission, 2018)

Highly critical views of Marsha Linehan and Matthew Large—i.e.,“Nosocomial suicides” which are suicides that are caused by hospitalization!

Coyle, Shaver, and Linehan (2018)—potential iatrogenic effects of psychiatric crisis services

Czyz, Berona, and King (2016)—readmission for suicidal teens significantly associated with more severe suicidal trajectory and suicide attempts

Typical inpatient stay: medication and some brief group work of 5-6 days (NAMI, 2014)

Hospitalization is associated with hundreds times greater risk for suicide deaths than general population (Qin & Nordentoft, 2005; Large et al., 2011).

5% of all post-discharge suicide occur within a week of discharge (Pirkota et al., 2005)

20% of all post-discharge suicides occur within one year of discharge (Desai et al., 2005)

Outpatients avoid talking about suicide for fear of hospitalization (Blanchard & Farber, 2018)

A one-size mindset and medications… Mann et al (2005): Treating mood and the underlying psychiatric disorder is “…a central

component of suicide prevention.”

Un-replicated RCT evidence for lithium (Tondo et al., 2001) and clozapine (Meltzer et al., 2003—only FDA approved Rx).

RCT’s not finding a SSRI effect on suicide ideation/behavior:

Gunnell et al (2005)

Ferusson et al (2005)

RCT’s that did find a SSRI effect on suicide ideation/behavior:

Zisook et al (2011)

Gibbons et al (2012)

Ketamine’s impact on ideation

Nitrous oxide? Limited RCT support for clozapine and lithium; very mixed results for SSRI’s…

Challenges to a “many-size” mindset: Status quo—despite the lack of evidence it is just too hard to change our

mindset about hospitalization and medication (magical/wishful thinking)

Health plans insufficiently cover effective suicide care (no suicide diagnosis)

Clinician fears about losing patients and particularly the fear of malpractice litigation paralyzes providers and fosters a “better safe than sorry” defensive practice attitude

Training issues (implementation/dissemination)—actually getting clinicians to use proven and effective treatments

The pervasive clinical care bias being the only approach that will work

The vast majority of suicidal people reject mental health care

The public relations battle—the general public and the media are still insufficiently concerned about the magnitude of this major public health issue

Changing the mindset: Lived Experience

Changing the Mindset: Policy Developments

1. Identifying suicide risk

2. Stabilization Planning

* National Lifeline

* Lethal means safety

3. Caring contact (follow-up)

Changing the mindset: Stabilization Planning

Changing the mindset: Lifeline and lethal means safety

1) Always provide Lifeline number2) Always discuss access to lethal means3) Verify that means have been secured4) Consider providing your own number

The importance of lethal means safety…

An idea that has been brewing for 24 years…

Could differential assessments of different suicidal states lead to different “prescriptive” treatments?

Suicidal Typologies: Different Suicidal StatesJobes (1995)

Intra-psychic vs. Inter-psychic

Agentic vs. Communal

Conrad et al (2009)

Acute vs. Chronic

Kleiman & Nock, 2017

Ecological Momentary Assessment (EMA)

Durkeim (1897)

Egoistic

Altruistic

Anomic

Fatalistic

Possible DSM-6 Diagnosis?

Rogers & Joiner (2017)

Acute Suicidal Affective Disturbance

Galynker (2017)

Suicide Crisis Syndrome

Josephine Au’s

Latent Profile

Analysis CUA

dissertation…

Internal Struggle Hypothesis ResearchWish to Live vs. Wish to Die

Kovacs & Beck, 1977;

Brown et al., 2005

Mayo Clinic

Cross-Sectional Study

O’Connor et al (2012)

Bryan et al

(2016)

SSF “Macro-Coding” RFL/RFD Motivation

LIFE MOTIVATION DEATH MOTIVATION

RFL = RFD RFL < RFDRFL > RFD

AMBIVALENT MOT.

A hybrid qualitative-quantitative approach

Written SSF responses and behavioral perseveration showing significantly increased ratings of

suicidal risk across two clinical data sets (Hamadi, Colborn, Bell, Chalker, & Jobes, in press)

Suicidal people are thus not the same; treatments should therefore be tailored to different suicidal states…

Lack of cognitive flexibility and

loss of cognitive control was

significantly associated with

increased ratings and frequency

of suicidal ideation…

Evidence-Based Treatments for Suicidal Risk There are 80+ RCT’s with suicidal ideation and

behavioral outcomes

There is no support for inpatient hospitalization; there is increased risk of suicide post-discharge

There are a handful of treatments with single RCT support in need of replication (e.g., ASSIP and mentalization-based therapy)

There are now well-studied suicide-specific interventions with replicated RCT support; these include:

Dialectical Behavior Therapy (DBT)

Two types of suicide-specific CBT (CT-SP & BCBT)

Collaborative Assessment and Management of Suicidality (CAMS)

Non-demand follow-up “caring contact”

Effective treatments for suicide attempters Dialectical Behavior Therapy (DBT)

Cognitive Therapy for Suicide Prevention (CT-SP)

Brief Cognitive Behavior Therapy (BCBT)

The Collaborative Assessment

and Management of Suicidality (CAMS)

The four pillars of the

CAMS framework:

1) Empathy

2) Collaboration

3) Honesty

4) Suicide-focused

Goal: Build a strong

therapeutic alliance

that increases patient-

motivation; CAMS targets

and treats patient-defined

suicidal “drivers”

First session of CAMS—SSF Assessment, Stabilization Planning,

Driver-Specific Treatment Planning, and HIPAA Documentation

CAMS Interim Tracking Sessions CAMS Outcome/Disposition Session

Summary of CAMS Research Findings to Date Across 8 published non-randomized clinical trials of CAMS, 1 meta-analysis,

and 4 published randomized controlled clinical trials, and 1 unpublished RCT (a total of 70+ publications):

CAMS quickly reduces suicidal ideation in 6-8 sessions

CAMS reduces overall symptom distress, depression, hopelessness, and changes

suicidal cognitions

CAMS increases hope and improves clinical retention to care

Patients like CAMS and the process of doing CAMS

CAMS works better with less severe patients at baseline presentation (impact with

borderline patients is mixed)

CAMS decreases ED visits among certain subgroups

CAMS appears to have a promising impact on self-harm behavior and suicide

attempts (but replication is needed)

CAMS is relatively easy to learn (adherence is typically attained with first patient)

Stephen O’Connor, Ph.D.A one-time psychological intervention on medical-surgical unit for attempters…

Peter Britton, Ph.D.1-2 sessions of Motivational Interviewingwith veterans following a suicide attempt…

BRIEF SUICIDE-SPECIFIC INTERVENTIONS…

Konrad Michel, M.D.

3 session intervention focused on narrative

interview, self-confrontation, safety plan, and

follow up...

Virtual CAMS for Suicidal Emergency Department Patients

NIMH-funded V-CAMS prototype was feasible in “proof of concept” SBIR Phase I

Patients engage “Dr. Dave,” peer-bridger videos, learn about coping skills, and receive psychoeducation about experience

In NIMH-funded Phase II RCT patients will get: “Waiting Well Patient Dashboard” and “Caring Tools to Go Mobile Apps” to potentially avert unnecessary inpatient admissions providing post-discharge support (e.g., caring contact)

The emerging tablet application is heavily influenced by lived-experience peers

Dr. Dave Demo

41

Motto’s Classic Caring Letter Study:

Simple letter sent every 1-4 months for 5 years

Source: Motto & Bostrom, 2001

Caring Contact Outreach Caring letters

Caring postcards

Caring phone calls

Caring emails

Caring texts

ED follow-up calls

Inpatient follow-up phone calls

Post-discharge home visits (e.g., VA)

Pillar #3:

Professional Consultation Consultation is a crucial professional activity.

You should seek a release to communicate with previous providers.

You should seek a release to communicate with consulting providers in on-going cases.

You should document information about your professional consultations.

Know the differences between consultation and supervision.

Pillar #4: DOCUMENTATION

HIPAA and the Medical Record

Health Insurance Portability

and Accountability Act (HIPAA)

Enacted by Congress in 1996, it came into effect April 2001; expected

compliance was April 15, 2003.

The law has changed many aspects of professional practice.

Three Main Rules:

1. Transaction Rule (electronic transmissions)

2. Privacy Rule (P&P; patient information—PHI)

3. Security Rule (physical infrastructure, offices, files, confidentiality, and

communications)

The HIPAA Privacy Rule

Privacy notice

Policies and procedures

Business services

Access to Protected Health Information

Documentation

Medical Record Progress Notes

Psychotherapy Notes

The Importance of Clinical Record Keeping

If you do not write it down, it did not happen

Write extensive initial medical record progress note

Be sure to write session-by-session contemporaneous progress notes

Try to write an extensive termination note (closing out the medical record)

What Goes into a Medical Record Progress Note?

1. Description of the Problem

2. History of the Problem

3. Mental Status Exam

4. Social and Family History

5. History of Prior Treatment

6. Description of Significant Medical and Psychosocial Problems

7. Brief Formulation

8. DSM IV Diagnosis (Axes I-V)

9. Treatment Plan (Goals and Objectives)

An Example of On-Going Medical Record NotePatient’s Name: John Doe Date/time seen: 3/ 3/17 9 am Payment: $600.00

Diagnosis: Adjustment Disorder/Depressed Mood—R/O substance abuse

Presenting Complaint: Pt. still struggling with his wife over financial issues, has been tempted to drink but has resisted so far;

work stress is interfering with sleep

Mental Status: WNL; Generally stable, no evidence of suicidal thoughts—mood depressed

Course of session: John is extremely stressed about work and home life. There have been various arguments and conflicts in

marriage that interrupt his sleep and he feels irritable and more depressed/anxious. Yet, he has resisted temptation to drink and

is using coping card/emotion regulation techniques effectively. Is eager to try medication and would like referral for couples

therapy with wife.

Treatment Plan: Continue in 1x/week psychotherapy, continue coping card/self-soothing techniques; begin Rx after meeting

with Dr. Doe; refer to Dr. Smith for couples tx.

Next appointment: STNW

Signature: Joe Dokes, LCSW

The Confusion over Medical Record Notes and the

Psychotherapy Note Exemption…

Bennett et al (2006) on psychotherapy notes:

“…the confusion regarding the appropriate use of psychotherapy notes is partially

a result of poor regulatory draftsmanship as well as a lack of guidance for when to

use and when not to use psychotherapy notes. The Privacy Rule itself is somewhat

vague about the psychotherapy notes…however, it is clear that psychotherapy

notes must be kept separate from the general medical record…”

What then is “good” documentation?

Medical record progress notes…

Must be contemporaneously maintained

Should emphasize objective facts of the case

These notes are always discoverable

Maintaining psychotherapy (personal) notes…

If allowed, you must physically store these notes separately from medical record

progress notes

There must not be overlapping information

These kinds of notes—when permitted—may not be discoverable but can be

produced in your defense.

Elements of a Good Record Continued Written and signed consent for treatment

Written treatment plan

Relevant history—past or present evaluations

Progress notes of sessions (significant events)

Notes of calls/communications

Notes of any consultations

Diagnostic and treatment decision making

No shows/cancellations

Instructions patient did/did not follow

Patients signed consent for disclosures

Notes of the beginning, middle, and end of care

Developing Usual and Customary

Practices and Policies and Procedures

The importance of having “usual and customary practices” from a professional and legal perspective.

For a range of tricky professional issues it always good to have a typical way of handling things.

Written policies and procedures are always protective (unless one does not follow them).

Case Example:

Being Stuck by Suicidal “Blackmail”

A clinical psychologist has worked with a highly dysregulated, anorexic, substance-abusing,

and depressed health care provider with a significant trauma history. In the first three years of

on-going (twice per week) psychotherapy, the patient made three suicide attempts by

overdose; each was followed by brief hospitalizations. A near-lethal jump from her 11th floor

apartment balcony prompted a longer-term hospitalization that was followed by admission to a

residential substance abuse treatment program. Seeking consultation from a trusted

psychologist colleague, the provider was stunned when the colleague gently suggested that

perhaps it was unethical to continue working with a treatment plan that plainly was not

working. The provider was stumped as to what to do next—it felt like being blackmailed by the

patient’s on-going suicidal risk.

Response to Suicidal Blackmail

Propose a major case review with the patient (and their family if

appropriate)

Consult with any collateral providers and trusted colleagues/experts about

treatment recommendations

Draft a summary report reviewing the work to date which concludes with

prospective treatment recommendations and requirements going forward.

Giving the patient/family three options:

To earnestly try a new treatment plan for finite period

To take referral to another provider (for care or 2nd opinion)

To take a break from treatment (if not in imminent danger)

Developing a Professional Backbone

Suicide-Related Malpractice Liability

Malpractice tort litigation for wrongful death secondary to a patient suicide is

pursued by plaintiffs (e.g., surviving family) who assert that the provide breached

the “standard of care”

The Standard of Care is operationally defined as what a reasonably prudent

practitioner who is similarly trained, in a similar settings, with a similar patient

would do.

Standard of care is defined by expert witnesses who examine subpoenaed records,

interrogatories, and depositions

The plaintiff has the burden of proof to establish that the practitioner:

Failed to assess the risk (i.e., forseeability)

Failed to appropriately treat the risk

Failed to follow-through on risk over the course of treatment

Consultation, Documentation,

and Working with Lawyers

Consultation and proof of consultation makes clear that you were not just on your own with the complexities of a difficult case.

In terms of clinical documentation, any plaintiff’s attorney will tell you: “If it was not written down, it didn’t happen…”

Recognize where trial lawyers are coming from—who they are and who they are not…

Use the APA book by Brodsky on testifying in court.

The Potential Horrors of Malpractice Litigation

Malpractice tort litigation is a plaintiff’s action whereby a list of complaints are made about various acts of omission or commission by the clinician that are said to be a direct or proximate cause of significant client injury or death…

The clinician’s practice will be judged retrospectively by experts on both sides of the case in relation to the “standard of care.”

Through a process of discovery and the taking of depositions, the case is revealed—the burden of proof lies with the plaintiff.

Most plaintiff’s cases go nowhere; some settle, fewer still go to trial—you never want to have to endure a malpractice trial as the defendant!

Malpractice Liability and Competent Practice

(Jobes & Berman, 1993)

Know and practice in accordance with the three pillars of protection from potential malpractice liability:

(a) Forseeability (assessment)

(b) Treatment planning

(c) Follow-up and follow-through

Forseeability and Assessment

A thorough assessment was conducted

Consider the possible use of assessment instruments

Consider the possible use of psychological testing

Make overall clinical judgments and document

Seek professional consultation and document the consultation

Treatment Planning

Use overall assessment to inform and shape treatment plan

Identify both short- and long-term treatment goals

Consider range of treatments—what will be used and why?

Consider various contingencies

Routinely revise and up-date treatment plan

Thoroughly document every aspect of the treatment plan

Overhaul treatment plan when necessary

Seek consultation and document the consultation

Follow-up and Follow-Through

Ensure that treatments are being implemented

Coordinate care with others as needed

Be sure to seek release to talk to previous providers

Always insure clinical coverage when unavailable

Carefully make referrals and follow-up (issues of clinical abandonment)

Seek consultation and adequately document follow-up and follow- through

The neuroscience of treatments

Suicidal people who do

not seek mental health care…

• Most suicidal people do not receive mental health care

• Many suicidal people do not want to seek mental health

care because of their attitudes towards mental health

• When they do seek care (e.g., ED-based care), they want

something different than what they get (e.g., a more

humanistic and person-centered response)

Lived-Experience Peer-Based Support

And the power of using technology to

reach more suicidal people at risk…

Matching Interventions to Different Suicidal States

(Jobes & Chalker, 2019)

Suicidal Populations (2017) Proven Interventions Universal Responses__________

(47K Suicide deaths)

10.6M Suicidal Ideators (SI)

1.4M Suicide Attempters (SA)

Dysregulated BPD Multi-SA’s

______________________________________________________________________________________________________________________________

Suicidal—not seeking treatment

_______________________________________________________________________________________________________________

StabilizationPlanning

+Lifeline

+Lethal Means

Safety+

Caring Contacts

CAMS

CT-SPBCBT

DBT

Public Education

+Lifeline

+CaringContact

Machine Learning?

Lived-

Experienced

Peer-Based

Support?

CAMS MI, ASSIP, TMBI

Stabilization Planning + Lethal Means Safety + caring follow-up used throughout the model

DBT, CT-SP, BCBT

Mental Health Service Corp—paraprofessionals (and people with lived experience) creating the necessary work force

Suicide-focused care that is: • evidence-based • least-restrictive• cost-effective

Thank You!Email: jobes@cua.edu