Lesson 6

Death is not the greatest loss in life. The greatest loss in life is what dies inside us while we live.
- Normal Cousins

There are few more difficult events in life than the suicide of a loved one; especially if it is witnessed. I simply cannot imagine the pain that would come from the death of a child, husband, wife, girlfriend, boyfriend, mother, father, grandmother, grandfather, cousin, aunt, uncle, or close friend at their own hands. How does someone go on after that? As most people who commit suicide do not leave notes, how do those left behind resolve the questions that will never be answered? Perhaps this is one reason why those who have experienced a suicide of a loved one are statistically more likely to do so themselves at some point in their lives? As days go on, we may start to think, "what did I miss?" Some family members and close friends of those who commit suicide often do not resolve this unfounded guilt. As they are able to look back after the death, they may start to identify many of the signs they "missed." Part of their grief process includes the attempt to resolve the self-blame on top of the other challenges resulting from such a loss. It becomes a crisis experience for many.

As future mental health professionals, it is imperative that you come to understand how suicidality is assessed and the mandatory reporting requirements that are incumbent upon you in those instances when someone is imminently suicidal. As one of the few legal requirements that mandate the violation of confidentiality, clinicians must take steps to prevent an impending suicide. In Maine, this process is called "Blue Papering" and "White Papering." You will learn about the warning signs that someone is potentially suicidal. While these issues are not black and white, several questions should be asked to determine the risk level of the person that you are working with.

Another unspeakable act is the purposeful killing of someone else- especially the murder of one's own children and/or spouse/significant other. As we have just finished the lesson on domestic violence, it is worth mentioning that homicide is often the end product of the cycle of violence. As you are probably aware, the most common pattern is the murder of the children, the spouse and then, the suicide of the perpetrator. It is the ultimate act of control and domination. Mental health professionals are also required to violate confidentiality if we assess that a potential homicide is imminent. We must do so regardless of whether the intended victim is known or not. In most states, not only do we need to notify the local authorities, we also are bound by what is termed the, "Duty to Warn" the intended victim. Maine does not currently mandate this through law. However, be aware of the significance of the Tarasoff case.

In the 1970s, a young male student at the University of California at Berkeley sought help at the campus counseling center. While in session with a clinician, he told the therapist that he intended to kill a young woman that he had been involved with romantically. Sadly, he did end up killing the young lady (her last name was Tarasoff). Soon thereafter, a successful civil law suit was brought by her family against the Regents of the University of California. As a result, the "Duty to Warn" or "Tarasoff Ruling" was put into California state law. Many other states enacted this law as well. In essence, this stipulates that, in addition to the required report to authorities, clinicians must make a reasonable attempt to obtain identifying information about any intended victim and immediately attempt to make contact and warn that individual. While most cases of homicide are perpetrated against an identified victim, as we have so tragically witnessed in the media, this is not always the case. The mass shootings perpetrated in the US (Columbine, Virginia Tech., Sandy Hook, etc), targeted victims completely at random. While the vast majority of the mentally ill are not dangerous, there is a small subset which have these tendencies. With the current laws and ethical standards mandating confidentiality in treatment, clinicians must carefully assess potential homicidality, and, within the bounds of state reporting laws, notify the authorities and, in many states, the intended victim. The problem with these laws is twofold. First, the legal wording of when the reporting threshold is reached is often quite vague (i.e. reasonable suspicion, imminent, current, etc). Given recent events, many states are now attempting to rework their statutes to allow providers to meet a less stringent threshold in order to violate the laws of confidentiality and trigger a report (New York was the first state. Those changes were made since the Sandy Hook massacre.). The second major issue concerns potential lawsuits for the violation of confidentiality if the threshold is not clearly met. Mental health providers can be sued and face state ethical charges should a report be made without clearly meeting the legal threshold. Of course, the same can be said if the report is not made when it should have been. Clinicians are at risk of violating "Duty to Warn" laws.

Please read the chapter closely. I want you to do your best to assess whether you think someone is potentially suicidal and/or homicidal based on the assessment process mentioned in the text.

After viewing the four talks at the end of the lesson- think about the types of crisis one can experience, the bio-psycho-social model, Maslow's hierarchy of needs, and the definition of crisis as PERCEPTION. Select at least ONE of these topics and discuss it in your post.

In this discussion we are going to evaluate the use of the app described below. This may be a resource that you would provide to family members who have others at risk. Download and review the app. Discuss how you might incorporate the use of this app in your practice. Does the app provide accurate and useful information?