This document provides guidance on ethics related to assessing and managing suicide risk in mental health patients. It outlines the professional responsibility to properly evaluate suicide risk through comprehensive assessment of current and historical factors. Relying solely on patient reports is insufficient. Admission is generally or may be needed depending on risk level and other criteria. The document also reviews specific information needed when reporting child abuse or neglect to authorities, such as description of injuries or neglectful supervision circumstances. Priorities for child protective investigations are also outlined.

1. Ethics in Mental Health
Erin A. Alexander, LPC
Rebecca D. Nate, LPC

2. Objectives
● Participants will be able to identify their professional responsibility as it
relates to patient suicide risk
● Participants will be able to identify the specific information needed when
reporting child abuse/neglect
● Participants will be able to identify the updates to the 2014 American
Counseling Association Code of Ethics, and the updates to the Health
Insurance Portability and Accountability Act
● Participants will be able to apply their knowledge of ethics to case
scenarios

3. Professional Responsibility and Suicide
Risk
The majority
of tort actions filed against mental health professionals
subsequent to a client's suicide are based on
allegations of negligence (such as failure to follow
established prevention guidelines) or malpractice (such as
misdiagnosis, absent or inappropriate risk assessment, or
inappropriate treatment interventions when
suicide risk was identified).

4. Did You Know?
Asking the client if he or she is suicidal,
if he or she has a plan, and if he or she
has the means to carry out the
plan is insufficient and reflective of
negligence.

5. Assessment of Suicide:
Current presentation of suicidality
• Suicidal or self-harming thoughts, plans, behaviors, and intent
• Specific methods considered for suicide, including their lethality and the
patient’s expectation about lethality, as well as whether firearms are accessible
• Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or
anxiety
• Reasons for living and plans for the future
• Alcohol or other substance use associated with the current presentation
• Thoughts, plans, or intentions of violence toward others

6. Assessment of Suicide
Psychiatric illnesses (psychosocial history)
• Current signs and symptoms of psychiatric disorders with particular attention
to mood disorders (primarily major depressive disorder or mixed episodes),
schizophrenia,
substance use disorders, anxiety disorders, and personality disorders
(primarily borderline and antisocial personality disorders)
• Previous psychiatric diagnoses and treatments, including illness onset and
course and psychiatric hospitalizations, as well as treatment for substance use
disorders

7. Assessment of Suicide
History (Psychosocial history)
• Previous suicide attempts, aborted suicide attempts, or other self-harming
behaviors
• Previous or current medical diagnoses and treatments, including surgeries or
hospitalizations
• Family history of suicide or suicide attempts or a family history of mental
illness, including substance abuse

8. Assessment of Suicide
Psychosocial situation (Current and Psychosocial history)
• Acute psychosocial crises and chronic psychosocial stressors, which may include
actual or perceived interpersonal losses, financial difficulties or changes in
socioeconomic status, family discord, domestic violence, and past or current sexual
or physical abuse or neglect
• Employment status, living situation (including whether or not there are infants or
children in the home), and presence or absence of external supports
• Family constellation and quality of family relationships
• Cultural or religious beliefs about death or suicide
• Individual strengths and vulnerabilities

9. Assessment of Suicide
Coping skills (Psychosocial history)
• Personality traits
• Past responses to stress
• Capacity for reality testing
• Ability to tolerate psychological pain and satisfy
psychological needs

10. Patient Reliability and Veracity
Patients are not always reliable sources of information,
especially about their suicidal wishes and impulses.
When a suicide has occurred, one of the things our
experts look for is evidence that the caregivers relied
solely on the patient for information about suicide risk.

11. Patient Reliability and Veracity
Clinical decision makers know, or should know, the many reasons
patients often provide inaccurate information in assessments. Cognitive
deficits or psychosis may make them incapable of giving a complete
history. They may want to avoid hospitalization or restriction. If already
hospitalized, they may want to be discharged or given a pass. They may
try to be honest with the examiner but be unable to assess their own
future impulses. They may simply want to mislead the clinician into
believing they aren’t suicidal so they will be free to kill themselves
without interference. By the same token, so-called no-self-harm
“contracts” are unreliable.

12. Where to Obtain Information
● Family Members, significant others
● Other mental health professionals
● Medical professionals
Be sure to have signed consents in the file
and signed coordination of care forms in
the file at the beginning of treatment

13. Admission Generally Indicated
After a suicide attempt or aborted suicide
attempt if:
• Patient is psychotic
• Attempt was violent, near-lethal, or premeditated
• Precautions were taken to avoid rescue or
discovery
• Persistent plan and/or intent is present
• Distress is increased or patient regrets surviving
• Patient is male, older than age 45, especially with
new onset of psychiatric illness or suicidal
thinking

14. Admission Generally Indicated
• Patient has limited family and/or social support,
including lack of stable living situation
• Current impulsive behavior, severe agitation, poor
judgment, or refusal of help is evident
• Patient has change in mental status with a
metabolic, toxic, infectious, or other etiology
requiring further workup in a structured setting
In the presence of suicidal ideation with:
• Specific plan with high lethality
• High suicidal intent

15. Admission May be Needed
• After a suicide attempt or aborted suicide
attempt, except in circumstances for which
admission is generally indicated

16. Admission May be Needed
In the presence of suicidal ideation with:
• Psychosis
• Major psychiatric disorder
• Past attempts, particularly if medically serious
• Possibly contributing medical condition (eg,
acute neurological disorder, cancer, infection)
• Lack of response to or inability to cooperate with
partial hospital or outpatient treatment

17. Admission May be Needed
• Need for supervised setting for medication trial
or electroconvulsive therapy
• Need for skilled observation, clinical tests, or
diagnostic assessments that require a structured
setting
• Limited family and/or social support, including
lack of stable living situation

18. Admission May be Needed
• Lack of an ongoing clinician-patient relationship
or lack of access to timely outpatient follow-up
• In the absence of suicide attempts or reported
suicidal ideation/plan/intent but evidence from
the psychiatric evaluation or history from others
suggests a high level of suicide risk and a recent
acute increase in risk

19. Transitioning Over to Child Protective
Reporting….
We are all aware of the procedures for
reporting child abuse/neglect. None of this has
changed and it is relatively the same across the
nation.
The issue is Specific Information Needed
When Reporting

20. Specific Information Needed When Reporting
Physical Abuse
● Identifying Information
● Description of injury, location, instrument,
size, shape?
● Punched, slapped, open or closed fist?
● Frequency?

21. Specific Information Needed When
Reporting Physical Neglect
● Weight change?
● Bleeding/infestation of lice?
● If you have done a home visit: exposed
wiring, broken windows, rat/roach
infestation, maggots, human/pet feces

22. Specific Information Needed When
Reporting Medical Neglect
● Has the parent been notified and been given the
opportunity to get help/treatment?
● Who is the family doctor (phone number) listed on the
emergency card?
● Does the child take medication at school? Who is the
prescribing doctor?
● How is daily functioning impaired?
Not likely to be assigned: lack of medical treatment that
does not pose risk of serious harm

23. Specific Information Needed When
Reporting Neglectful Supervision
● Are latchkey kids waiting inside or outside of the home?
● Do they know what to do in case of an emergency?
● Do they have access to a phone/neighbor?
● Level of functioning, special needs, or behavioral
concerns?
● Are they watching younger siblings?
● Are they home alone?
Not likely to be assigned: latchkey kids age 6 and older, delinquent behavior by
child age 10 and older, reportedly dangerous animals present but no history of
injury to the child

24. Priorities for Investigations
● Priority 1 (immediate and within 24
hours)
● Priority 2 (within 72 hours)
The Agency assesses and determines the level of risk as it
related to possible harm to the child. The Agency has its
own assessment tools.

25. References and Resources for this
Portion of the Presentation
http://psychiatryonline.org/content.aspx?bookID=28&sectionID=1673332#5607
3
http://www.biomedsearch.com/article/Death-throes-professional-liability-
after/131605687.html
http://www.stopasuicide.org/docs/APASuicideGuidelinesReviewArticle.pdf
http://www.dfps.state.tx.us/Contact_Us/report_abuse.asp