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Suicide and the law

Posted on November 20, 2012 at 8:02 AM Comments comments (149)
To follow through with the topic of suicide, here is a summary of the chapter titled "Suicide and refusal to accept life-saving treatment" from the book "Standards and Ethics for Counselling in Action" by prof. Tim Bond.

Tim Bond is an expert in professional ethics applied to counselling. He is the architect of the BACP Ethical Framework for good practice in Counselling and Psychotherapy

In the chapter on suicide, the author considers the dilemmas concerning working with a suicidal client, when the client refuses additional help or treatment, and discusses the law's in relation to autonomy, consent, mental capacity and confidentiality. 

Life is sacred
Therapists generally find themselves in two different camps. Some take the stance that life is sacred and has intrinsic value and the therapist's duty is to preserve it. Questioning the value of one's life is symptomatic of mental illness. The individual should be protected against suicidal feelings, which are often transient. This stance is embraced by many mental health professionals who work within the remit of preventing suicide. 

The alternative view is that every person has a right to choose, and suicide is an expression of choice. There are occasions when death may be preferable to life. The therapists that embrace this view tend to disagree with the medicalisation of mental illness.  

Tim Bond suggests that becoming entrenched in one position or other may be more for the benefit of the therapist, who is attempting to control their own anxiety about dealing with a client's death. In fact, the appropriate response is to weigh each individual case and be sensitive to each client's individual circumstances, thus allowing for a degree of flexibility and adaptability which is more facilitative than taking a rigid position. 

The English law
The held assumption that the therapist's duty of care is to protect the client from suicidal intent, may be based on misapplications of US law, says Tim Bond. In the states counsellors are required to breach confidentiality to report suicidal intent, but "there is no equivalent in Britain". "There is no general or automatic legal obligation to intervene on behalf of an adult who is suicidal or refusing medical treatment" (p.119)

Individual autonomy
In fact the English law is strongly favours the individual's autonomy unless there is evidence that the person is of unsound mind, that is suffering a diagnosable mental illness or is being coerced. 

Counsellors may suggest that the client access their GP, psychiatrist or community mental health team, but should be extremely cautious in breaching confidentiality against the clients' wishes. Clients frequently refuse to be treated by their GP because of a fear that their medical reports will be disclosed to their employers. 

If the counsellor insists on breaching confidentiality against the client's wishes they "could be liable for substantial damages for loss of earnings if the client's career were to be adversely affected by an inappropriate disclosure" (p. 107)

Therapists working independently of the NHS mental health services have no general duty to intervene. However therapists working with patients receiving compulsory mental health treatment under the Mental Health Act 2007 may have to follow the protocols agreed as part of the terms of their employment. 

Confidentiality
For breaching of confidentiality against the client's wishes to be defensible, the therapist hast o believe that the client is seriously at risk of committing suicide and is suffering from a mental disorder (depression, schizophrenia, bipolar affective disorder). 

My note on this: although some psychotherapists are familiar with the DSM and have embraced the use dual diagnosis, we do not have the same remit as a trained psychiatrist to ascribe diagnostic labels. So arguing that a client has a mental disorder when in fact they have not been so diagnosed by their GP or an assessing psychiatrist may be problematic as far as I can see. We could easily be contradicted by a psychiatry expert. 

Crucially, the Mental Health Act excludes promiscuity, alcohol and drug abuse from compulsory treatment. 

Adult clients have the right to refuse life saving treatment. Therapists may challenge and explore the client's views but have to respect the client's right to make a decision for themselves, if they have the capacity to do so (evidence of capacity depends on whether the someone can retain information long enough to make a decision and whether they are able to weigh different options). Tim Bond stresses that the Mental Health Act cannot be used to achieve "the detention of an individual against her will merely because her thinking process is unusual, even apparently bizzarre and irrational, and contrary to the views of the overwhelming majority in the community at large".

Uncomfortable tension
What Tim Bond's exposition highlights for me is what I see as an uncomfortable tension between the law's respect for personal autonomy going all the way back to the Magna Carta and the current medicalisation of psychotherapy. The Department of Health policy to prevent and reduce suicide seems to create a culture in which NHS staff are pressured into standards of care and management of risk that may be at odds with the principles of confidentiality and autonomy. The latest report I have read on Schizophrenia suggests that the use of coercive treatment is on the rise. My own experience working for IAPT has informed me that even for clients without a formal psychiatric diagnosis, prevention is placed above the principle of confidentiality. 

It is understandable that clients seek treatment in an alternative, non-medical culture, but the independent provision of psychotherapy and counselling services is increasingly under the influence of a medical-model. Perhaps independent therapists begin to subscribe to this because the standards of care set by the medical model are part of a government-backed policy and thus appear to have legitimacy. There is also a fear of being accused of malpractice, and yet considerable confusion about what constitutes good practice, as different therapists have different views on this. Furthermore, therapists may want to do everything they can to avoid for themselves the pain and extreme anxiety caused by a client's suicide, which would throw into question of their competence by peers and supervisors and make them vulnerable to criticism and maybe even prosecution. 

Bereaved relatives of clients who have completed suicide may project their anger and grief onto the therapist, making accusations of incompetence or not caring. The therapists may feel torn between ethical, moral and legal principles that may at times feel at odds with each-other and make ethical dilemmas around suicide extremely difficult to navigate. 

Death and the doctor

Posted on November 19, 2012 at 4:52 PM Comments comments (1)
After hearing dr. Elaine Kasket on Digital Human I became interested in her research on the many facets of how we experience death and mourn. I found two articles Death and the Doctor published by Dr. Kasket in the Journal of Existential Analysis (2006). These are extracts from her doctoral thesis. (Death and the Doctor I and II) I was excited to find this research because it links in with my current interest into how the death of a client through suicide is affecting mental health clinicians such as psychotherapists, counsellors psychiatrists and clinical psychologists. 

Ultimate rescuer
Dr. Kasket is reflecting on the status of the physician in relation to the modern experience of dying.  She says: “With the modern decline of religion and elevation of science and technology, the fight against death is a war, with the charge led by the physician. Society and patients cast physicians in a highly pressurized role that is both potentially rewarding and potentially awkward” (p. 137) The doctor thus  becomes the "ultimate rescuer" (Yalom, 1980), a role both imposed and eagerly accepted by the physician, who may himself be motivated to enter the medical field by a personal need to overcome his death anxiety. 

"Be strong" as a professional norm
Dr. Kasket reviews the existing literature on how doctors' responses to their patients and their suffering or demise is subtly shaped by their training and work culture. Physicians supervise their own emotional response by considering informal professional norms and client expectations.
 
“When emotional expression is discouraged and not allowed space, when faculty members do not ask about students’ affective responses, when it is explicitly stated that too much emotional involvement will interfere with good patient care, and when hard work and academic pressures are so strong as to cause emotional blunting, medical students get the message that negative emotions and their management are a private matter and their own “problem”, to be dealt with by themselves and not part of their professional development” (p. 140)

Physicians are expected to maintain “affective neutrality” – a highly valued aspect of professional identity, associated with power, knowledge and being above challenge. The underlying assumption seems to be that an effective physician does not become emotionally involved with patients. 

Strategies against the experience of emotional pain
Defense mechanisms such as intellectualisation, use of scientific technical language, thinking about the patient as a "case",  black humour and  suppression of feelings are learned and employed, leading to blunted emotional awareness and a reduced capacity to communicate effectively. 
 
Other emotion management strategies employed by doctors are: deflecting attention from personal feelings, blaming the patient, making the patient responsible for the doctor’s feelings, projecting. Some doctors may choose specializations where they believe they are less likely to be confronted by death – such as psychiatry, cosmetic surgery, pathology.

Dr. Kasket conducted a qualitative research into the experience of eight doctors and found that they are impacted deeply by the death of their patients and become frequently experience grief and a radical re-assessment of their professional capacity. 
 
“The dying patient challenges physician’s carefully constructed and reinforced view of themselves that they are experts, who know what is wrong and who know what needs to be done to cure the patient. Not being able to effect that cure can lead to identity confusion, feelings of personal failure and self-esteem crises. (…) After a death, physicians are left doubting themselves: Did they do something wrong? Could something more have been done to prevent the death? Is their grief reaction abnormal? Will it interfere with their work?” (p.144)
 
Physicians who lose clients become uncertain about diagnosis and about treatment. Terror of making a mistake that could result in death, which could provoke a crisis of identity and have important consequences legally and professionally.
 
Common coping strategies include: seeking support socially, self-talk, avoidance and wishful thinking. Negative strategies: lashing out, blaming self and others, taking alcohol or drags, intellectualisation, avoidance, crying. They may not be able to take time to reflect or have a private emotional moment. Other behaviours: heroic attempts to sustain life, resuscitation at any cost, unnecessary tests for a patient who is dying, over-prescribing medication.

Death and the digital world

Posted on November 19, 2012 at 10:20 AM Comments comments (1)
How much of us is there beyond the physical? Listen to this episode of Digital Human

Mike uses eye-tracking technology to share his thoughts and views online. In the real world he is confined to a wheel chair and is completely paralysed. 

Elaine Kasket (counselling psychologist) speaks to bereaved people who carry on preserving the digital selves of those who died. She says that our digital selves are confusing because they can seem permanent on one hand, but can also vanish instantly and thus seem ephemeral and fragile. Her clients experience Facebook as the primary channel through which they can connect the dead, a modern-day version of a Victorian medium. Whether they are religious or not, many of them believe that they are able to continue to communicate with the lost ones in the digital sphere.

Computers are our social secretary and confessor. When we die we leave behind a ghost of ourselves: our thoughts, the important, the unimportant, the  daily, the momentous. In a sense, digital afterlife has been achieved through Facebook accounts that remain active and email auto-responder. 

Links: 

On academia.edu you can find some Dr. Elaine Kasket' articles: