If you're like me, you may be wondering whether the case of a young woman who was found guilty on Friday of involuntary manslaughter relates to our clinical work. She encouraged her boyfriend to follow through on his suicide attempt by telling him via text message to get back into his truck that was laden with carbon monoxide.
Certainly, the case has—and will have—legal implications as well as moral ones. But are there psychiatric ones?
Perhaps we will eventually learn more about the clinical care of both teenagers. So far, the news has reported that she herself had tried to commit suicide, that she had an eating disorder and had gone through six therapists. The judge in the Massachusetts trial did consider her a “youthful offender,” and her psychiatric state certainly could have affected her thinking process adversely.
Early in the teens’ two-year relationship, the young girl encouraged her boyfriend to seek treatment for his depression, but we don't yet know if he did and, if so, what that encompassed. Likely for ethical reasons of confidentiality, we may never be able to satisfy our curiosity and be able to assess the clinical care that was provided. Sometimes, enough information is available to do a psychological autopsy in a suicide.
Obviously, we should never encourage our own suicidal patients to complete suicide, even if we are doing some version of paradoxical psychotherapy. However, this case may intensify our own concerns of our clinical responsibility for patients who are suicidal. When are we and/or the system we work in responsible to any degree?
Research suggests that we are poor predictors of which patient will go on to commit suicide. We do know that many patients who surprisingly survive a serious attempt are later grateful for their survival, especially if they receive good follow-up care. Thankfully, suicide is rare among our patients, but emotionally devastating to any clinician if it happens.
Often, patients won't tell us of their intent, even if we competently inquire about it. We have to keep in mind such risk factors as anxiety, accompanying severe depression, loneliness, reduced cognitive ability, commanding auditory hallucinations and a lack of religious prohibition. Even if we assess a high risk, getting someone into a hospital who doesn't want to go there seems to be perversely difficult in the many states that legally insist upon demonstrative suicidal behavior first.
Personally, I only had one patient follow through with suicide in my 40 year career, and it happened way back in my first year of training.
How responsible was I? I still wonder at times. I know that I had limited knowledge and skills at the time, including being unable to appreciate that sudden, unexplainable improvement might be a clue for a suicide decision. Though I was never sued, there have been successful suits against clinicians and systems for patients who have committed suicide or homicide or experienced serious side effects of prescribed medication.
Sometimes, we try to use clinical contracts with patients to reassure ourselves that the patient will not commit suicide. However, even if a patient signs such a contract, it is not legally binding, nor clinically foolproof. Much more important is a positive therapeutic alliance.