CorrectCare

Assessing Suicide Risk
Taking It Step by Step Is Your Best Bet
by Thomas W. White, PhD

When it comes to suicide, correctional populations are a tough case. Many inmates possess the risk factors—historical, environmental and psychological—that increase the probability that they may attempt suicide. Not surprisingly, suicide has been identified as the leading cause of death in U.S. prisons.

Adding insult to injury, correctional facilities and their health care services are highly visible, and increasingly common, targets for subsequent litigation.

Despite those unique difficulties, correctional health care providers can—and should—adhere to the same principles of suicide assessment as their counterparts in the free world. In fact, in the all-too-likely event of a law-suit, the court undoubtedly will hold them to community standards of care.

Clearly, to avoid any claims of clinical or legal liability, it’s in clinicians’ best interests to not only provide effective care and management of suicidal clients, but to protect themselves, as much as possible, against the threat of malpractice litigation.

The best way to achieve those goals is to conduct risk assessments that are clinically sound, professionally responsible and legally defensible.

Unfortunately, formal training on suicide assessment has been sorely lacking. As a result, assessment too often is an idiosyncratic process, guided primarily by the experience, bias or common sense of the person doing the evaluation.

Instead, clinicians should become familiar with the legal concepts underlying malpractice litigation, and, most importantly, should ensure that each evaluation follows a consistent, logical process that provides a clear rationale for decisions made in managing the case. Such an approach will not only strengthen the evaluation and treatment, but also decrease the chance of successful litigation.

LEGAL HAZARDS
Why is litigation becoming such a predictable consequence of inmate suicide? The reasons vary, but the most common ones include the fact that ours has become a litigation-oriented society, always expecting perfection and blessed with 20/20 hindsight, which makes blaming easy. Add to that any perceived mental health “emergencies,” and lawsuits are almost inevitable.

Given this state of affairs, it’s crucial to clarify the relevant legal issues. First, it is the process, not the outcome, that is critical in evaluating the adequacy of a suicide assessment. A second serious issue is whether the organization has a written policy governing suicide assessment, whether that policy was complied with, and whether documentation exists to confirm compliance. Finally, it must be remembered that health care providers never “ensure” life.

Most lawsuits against mental health practitioners are tort actions, civil suits alleging that the defendant has caused harm to another. The three basic types of tort actions are negligence (failure to act in a reasonable and prudent manner), malpractice (failure to meet professional standards through negligent performance) and deliberate indifference (failure to provide minimum care intentionally, a serious breach of constitutional rights).

A successful tort action generally will establish the following points: A relationship exists between clinician and client that creates a duty. The clinician’s professional conduct was below the accepted standard. The client was actually harmed. The clinician’s conduct caused the harm.

For a correctional health care provider, the best protection against litigation can be summed up in four rules: Know the accepted suicide risk factors. Document with sufficient detail and accuracy. Think prospectively. Follow organization policy.

Should legal defense be required, documented compliance with policies and procedures will prove invaluable. Any omission or deviation can spell trouble, as evidenced in this list of the six most common sources of liability:

• Failure to conduct an adequate assessment
• Failure to respond to threats or gestures
• Failure to take effective action or develop a treatment/management plan
• Failure to monitor adequately the behavior of suicidal clients
• Failure to respond or follow up
• Failure to maintain adequate records, or altering or destroying records

A SYSTEMATIC METHOD
What is actually being assessed during a suicide evaluation? There are several overlapping issues:

• The likelihood a self-destructive act will occur
• The likelihood death will result from the act
• The potential severity of the act, if not fatal
• The need for and level of intervention required

An important point is that risk shifts along a continuum. It’s helpful to conceptualize lethality as an equation:

LETHALITY = (KNOWLEDGE + MEANS + PLAN) X INTENT

All elements must be present for an attempt or suicide to occur, and the degree of lethality correlates to the relative strength of each element.

Since lethality is an ever-changing condition, predictability is limited. Nevertheless, a structured, multidimensional approach will provide clinicians with keen insights and help them devise appropriate treatment plans. (See “Six Essential Steps for Suicide Assessment” below.)

The primary tool is the assessment interview. Information being sought includes: factors that put the client at high risk for suicide; any mental illness and degree of illness; intellectual competence; and degree of client’s veracity and cooperation.

Once the data is collected, it must be analyzed and the client assigned to a risk category. A caveat: Since suicidal behavior occurs along a continuum, any classification system will, by necessity, be imperfect. Still, defined categories can aid in logical decision-making about risk level. A classification system might look like this:

• High/extreme risk. Most risk factors: lethal plan/attempt, strong intent, hopelessness, stress, diagnoses, stressors, low support, chronic dysfunction
• Moderate risk. Several risk factors: prior gestures/acts, moderate to low intent or high intent with low lethality, plan/thoughts, diagnoses, stressors
• Low risk. Some risk factors: family/personal history, some low-intent acts, current stressors, drug abuse, diagnoses
• No/minimal risk. Few if any risk factors: vague thoughts, some verbalizations, current stress, minimal support

The all-important documentation should contain the interview information, assessment analysis and findings, and treatment plan. In developing a treatment plan, the clinician should explore the full range of options available, and establish a rationale for decisions and actions taken. The clinician also must ensure that the plan is implemented, and do follow-up.

It’s also a good idea to seek peer consultation, which can validate—or challenge—the clinician’s conclusions, decisions and actions. This not only aids in decision-making, but also demonstrates evidence of concern and thoroughness and provides extra documentation.

SUMMING UP
For many health care providers, including those specializing in mental health, suicide is one of the most distressing aspects of their jobs. The deliberate self-inflicted death of a client will always be jarring, but the lawsuit that may follow can be devastating. By using a logical, systematic approach to assessment, clinicians will help both their clients and themselves.

— About the author: Thomas W. White, PhD, is a principal with Training and Consulting Services, Kansas City, KS. He’s also regional administrator of psychology services at the Federal Bureau of Prisons. This article is based on a seminar he presented at the Clinical Updates in Correctional Health Care conference in May 2001. White also wrote a book on this topic, How to Identify Suicidal People.

To reach White, e-mail consult@suicideconsultant.com, or visit the Web at www.suicideconsultant.com. To order the book, e-mail ncchc@ncchc.org, or call (773) 880-1460. To order an audiotape, visit Nationwide Recording Service at www.nrstaping.com.

[This article first appeared in the Summer 2001 issue of CORRECTCARE.]